Provider Demographics
NPI:1417405002
Name:ROBERTSON, VERNON
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-3335
Mailing Address - Country:US
Mailing Address - Phone:662-369-2455
Mailing Address - Fax:
Practice Address - Street 1:400 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-3335
Practice Address - Country:US
Practice Address - Phone:662-369-2455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered