Provider Demographics
NPI:1336638683
Name:ROBERTS, DAENA
Entity Type:Individual
Prefix:
First Name:DAENA
Middle Name:
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 1:11624 METROPOLITAN AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1017
Mailing Address - Country:US
Mailing Address - Phone:718-847-2020
Mailing Address - Fax:718-847-9457
Practice Address - Street 1:11624 METROPOLITAN AVE FL 2
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1017
Practice Address - Country:US
Practice Address - Phone:718-847-2020
Practice Address - Fax:718-847-9457
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009224156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician