Provider Demographics
NPI:1154835403
Name:ROBERTS, SANDRA JEAN
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
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 1:5930 LAKE RD W UNIT 903
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-8523
Mailing Address - Country:US
Mailing Address - Phone:440-228-5824
Mailing Address - Fax:
Practice Address - Street 1:5930 LAKE RD W UNIT 903
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-8523
Practice Address - Country:US
Practice Address - Phone:440-228-5824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-23
Last Update Date:2017-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health