Provider Demographics
NPI:1326235730
Name:ROBERTS, SUSAN K (RN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:K
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N9520 BLACK RIVER LN
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:MI
Mailing Address - Zip Code:49911-9781
Mailing Address - Country:US
Mailing Address - Phone:906-667-0534
Mailing Address - Fax:
Practice Address - Street 1:N9520 BLACK RIVER LN
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:MI
Practice Address - Zip Code:49911-9781
Practice Address - Country:US
Practice Address - Phone:906-667-0534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-29
Last Update Date:2007-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35019000Medicaid