Provider Demographics
NPI:1114550506
Name:ROBERTS, KATLYN (RN, MSN, CPNP)
Entity Type:Individual
Prefix:
First Name:KATLYN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RN, MSN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60160 E 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60160 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-9768
Practice Address - Country:US
Practice Address - Phone:248-431-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704321713363LP0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics