Provider Demographics
NPI:1275255770
Name:ROBERSON, KOURTNEY
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:ROBERSON
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 1:4731 JUDY DR
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-3815
Mailing Address - Country:US
Mailing Address - Phone:405-370-9909
Mailing Address - Fax:
Practice Address - Street 1:4731 JUDY DR
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3815
Practice Address - Country:US
Practice Address - Phone:405-370-9909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PWR0105941163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse