Provider Demographics
NPI:1164413712
Name:ROBERTS, LISA JO (CNM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JO
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HAGGERTY LANE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401
Mailing Address - Country:US
Mailing Address - Phone:540-414-8585
Mailing Address - Fax:540-414-8597
Practice Address - Street 1:18 HAGGERTY LANE
Practice Address - Street 2:SUITE 103
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401
Practice Address - Country:US
Practice Address - Phone:540-414-8585
Practice Address - Fax:540-414-8597
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024158784367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010089832Medicaid
S72388Medicare UPIN
VA010089832Medicaid