Provider Demographics
NPI:1275910218
Name:PIERRE, ROBERTA
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:PIERRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:PIERRE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ROBERTA PIERRE
Mailing Address - Street 1:10960 BEACH BLVD LOT 32
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-4831
Mailing Address - Country:US
Mailing Address - Phone:904-328-6904
Mailing Address - Fax:904-328-6946
Practice Address - Street 1:10960 BEACH BLVD LOT 32
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-4831
Practice Address - Country:US
Practice Address - Phone:904-328-6904
Practice Address - Fax:904-328-6946
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL233862171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011682200Medicaid