Provider Demographics
NPI:1437193711
Name:ROBERTS, LISA R (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4402
Mailing Address - Country:US
Mailing Address - Phone:909-798-6524
Mailing Address - Fax:909-792-0858
Practice Address - Street 1:1201 BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4402
Practice Address - Country:US
Practice Address - Phone:909-798-6524
Practice Address - Fax:909-792-0858
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18676363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR268622Medicaid
P45042Medicare UPIN
OR268622Medicaid