Provider Demographics
NPI:1417362351
Name:ROBERTSON, NICOLE (SRNA)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:SRNA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BRASE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1415 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-2720
Mailing Address - Country:US
Mailing Address - Phone:217-370-3762
Mailing Address - Fax:
Practice Address - Street 1:1415 RIDGE ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-2720
Practice Address - Country:US
Practice Address - Phone:217-370-3762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA137399207L00000X
IL209028100367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology