Provider Demographics
NPI:1114391588
Name:ROBERTS, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:ROBERTS
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 1:504 S AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-7222
Mailing Address - Country:US
Mailing Address - Phone:530-802-1095
Mailing Address - Fax:
Practice Address - Street 1:504 S AUBURN ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7222
Practice Address - Country:US
Practice Address - Phone:530-802-1095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-21
Last Update Date:2015-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 272908164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse