Provider Demographics
NPI:1407835101
Name:DACUS, ROBERTA ANN (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:ANN
Last Name:DACUS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HORIZON RIDGE CV
Mailing Address - Street 2:
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-2079
Mailing Address - Country:US
Mailing Address - Phone:915-208-3468
Mailing Address - Fax:
Practice Address - Street 1:530 5TH AVE FL 10
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-5114
Practice Address - Country:US
Practice Address - Phone:917-261-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704379404363LF0000X
CA20496363LF0000X
COC-APN.0001472-C-NP363LF0000X
WAAP30006084363LF0000X
NY348412363LF0000X
IL209.025719363LF0000X
TXAP107088363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
154934OtherLYI
WA9632647Medicaid
MD0309561OtherDEA
154934OtherLYI
MD0309561OtherDEA