Provider Demographics
NPI:1073145397
Name:ROBERISON, NICOLLETTE
Entity Type:Individual
Prefix:
First Name:NICOLLETTE
Middle Name:
Last Name:ROBERISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:LA
Mailing Address - Zip Code:71067-8343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1217 WINFIELD RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:LA
Practice Address - Zip Code:71067-8343
Practice Address - Country:US
Practice Address - Phone:318-286-7225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer