Provider Demographics
NPI:1043988868
Name:ROBERTS, KATHRYN (OWNER)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 N 138TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-6055
Mailing Address - Country:US
Mailing Address - Phone:402-981-7852
Mailing Address - Fax:
Practice Address - Street 1:5115 N 138TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-6055
Practice Address - Country:US
Practice Address - Phone:402-981-7852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X, 376J00000X
NE372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE69457794Medicaid