Provider Demographics
NPI:1265016463
Name:ROBERTS, KATINA MICHELLE
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:MICHELLE
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:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39355-0272
Mailing Address - Country:US
Mailing Address - Phone:601-616-8169
Mailing Address - Fax:
Practice Address - Street 1:212 WILLOW ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:MS
Practice Address - Zip Code:39355-2243
Practice Address - Country:US
Practice Address - Phone:601-616-8169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health