Provider Demographics
NPI:1063657617
Name:ROBERTSON, BEVERLY DIANNE (WHNP)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:DIANNE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:PEARSON
Mailing Address - State:GA
Mailing Address - Zip Code:31642-0218
Mailing Address - Country:US
Mailing Address - Phone:912-422-3332
Mailing Address - Fax:912-422-7345
Practice Address - Street 1:636 A E. AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:PEARSON
Practice Address - State:GA
Practice Address - Zip Code:31642
Practice Address - Country:US
Practice Address - Phone:912-422-3332
Practice Address - Fax:912-422-7345
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN044298163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse