Provider Demographics
NPI:1194216911
Name:ROBERTS, DONNA MARIE
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:MARIE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:33883 COUNTY ROAD PP
Mailing Address - Street 2:
Mailing Address - City:WRAY
Mailing Address - State:CO
Mailing Address - Zip Code:80758-9034
Mailing Address - Country:US
Mailing Address - Phone:970-630-1679
Mailing Address - Fax:
Practice Address - Street 1:1017 W 7TH ST
Practice Address - Street 2:
Practice Address - City:WRAY
Practice Address - State:CO
Practice Address - Zip Code:80758-1420
Practice Address - Country:US
Practice Address - Phone:970-332-4895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0993811-NP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care