Provider Demographics
NPI:1083968978
Name:ROBERTSON, TAMRA R (CPNP)
Entity Type:Individual
Prefix:
First Name:TAMRA
Middle Name:R
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:TAMRA
Other - Middle Name:R
Other - Last Name:EHLTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:812-353-3087
Mailing Address - Fax:
Practice Address - Street 1:350 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5001
Practice Address - Country:US
Practice Address - Phone:812-335-2434
Practice Address - Fax:812-335-7604
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006229A363LP0200X
IL209-009796363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid