Provider Demographics
NPI:1407966062
Name:ROBERTSON, TERESA A (CNM RN)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:A
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:CNM RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POB 3111
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:CO
Mailing Address - Zip Code:80466-3111
Mailing Address - Country:US
Mailing Address - Phone:303-258-3904
Mailing Address - Fax:303-258-3284
Practice Address - Street 1:3011 NORTH BROADWAY
Practice Address - Street 2:SUITE 23
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302
Practice Address - Country:US
Practice Address - Phone:303-258-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO90674NUBURG176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02906746Medicaid