Provider Demographics
NPI:1093848004
Name:ROEBUCK, HEATHER (DNP)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:ROEBUCK
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5807 W MAPLE RD
Mailing Address - Street 2:SUITE 171
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4483
Mailing Address - Country:US
Mailing Address - Phone:248-862-6269
Mailing Address - Fax:248-862-6382
Practice Address - Street 1:5807 W MAPLE RD
Practice Address - Street 2:SUITE 171
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4483
Practice Address - Country:US
Practice Address - Phone:248-862-6269
Practice Address - Fax:248-862-6382
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704210386363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner