Provider Demographics
NPI:1093485203
Name:ROBERTS, COURTNEY (LVN)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 TULLY TRL
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:TX
Mailing Address - Zip Code:75791-3127
Mailing Address - Country:US
Mailing Address - Phone:903-921-0060
Mailing Address - Fax:
Practice Address - Street 1:1510 S VINE AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2826
Practice Address - Country:US
Practice Address - Phone:903-526-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-18
Last Update Date:2021-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3266702083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine