Provider Demographics
NPI:1417649633
Name:ROBERTSON, TERRA (NP)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 WALL ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3885
Mailing Address - Country:US
Mailing Address - Phone:812-288-4304
Mailing Address - Fax:
Practice Address - Street 1:1919 STATE ST STE 340
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6807
Practice Address - Country:US
Practice Address - Phone:812-945-5233
Practice Address - Fax:812-945-2804
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28217030A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300079969Medicaid