Provider Demographics
NPI:1336121128
Name:ROBERTS, SANDRA JOAN (RN, BSN, PT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JOAN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RN, BSN, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 HORNE BR
Mailing Address - Street 2:PO BOX 910
Mailing Address - City:STAFFORDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41256-9070
Mailing Address - Country:US
Mailing Address - Phone:606-297-6658
Mailing Address - Fax:
Practice Address - Street 1:83 DEWEY ST
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-7923
Practice Address - Country:US
Practice Address - Phone:606-886-9888
Practice Address - Fax:606-886-9416
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002279225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY87001467Medicaid
KY87001467Medicaid
KY1C 0936101Medicare PIN