Provider Demographics
NPI:1194035220
Name:ROBERTS, JANE ANNE (RN, COTA/L)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:ANNE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RN, COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 CECELIA DR NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4714
Mailing Address - Country:US
Mailing Address - Phone:860-303-3527
Mailing Address - Fax:
Practice Address - Street 1:232 CECELIA DR NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4714
Practice Address - Country:US
Practice Address - Phone:860-303-3527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03-893788163W00000X
CT03-882186224Z00000X
FLOTA 11327224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant