Provider Demographics
NPI:1114579000
Name:ROBERTS, TAMBRA LATRICE
Entity Type:Individual
Prefix:
First Name:TAMBRA
Middle Name:LATRICE
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 1:515 HWY 178 EAST HOLLYSPRINGS
Mailing Address - Street 2:
Mailing Address - City:HOLLYSPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-2523
Mailing Address - Country:US
Mailing Address - Phone:662-274-3211
Mailing Address - Fax:
Practice Address - Street 1:515 HWY 178 EAST HOLLYSPRINGS
Practice Address - Street 2:
Practice Address - City:HOLLYSPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-2523
Practice Address - Country:US
Practice Address - Phone:662-274-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide
No385H00000XRespite Care FacilityRespite Care
No372600000XNursing Service Related ProvidersAdult Companion