Provider Demographics
NPI:1134477870
Name:ROBERTSON, CODIE M (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:CODIE
Middle Name:M
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5330 STUART AVE
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2262
Mailing Address - Country:US
Mailing Address - Phone:208-221-6187
Mailing Address - Fax:
Practice Address - Street 1:110 VISTA DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4520
Practice Address - Country:US
Practice Address - Phone:208-234-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1210A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily