Provider Demographics
NPI:1467451708
Name:ROBERTS, MICHELE (GNP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6209 MID RIVERS MALL DR
Mailing Address - Street 2:SUITE 317
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63304-1102
Mailing Address - Country:US
Mailing Address - Phone:636-294-5735
Mailing Address - Fax:636-294-1566
Practice Address - Street 1:6209 MID RIVERS MALL DR
Practice Address - Street 2:SUITE 317
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63304-1102
Practice Address - Country:US
Practice Address - Phone:636-294-5735
Practice Address - Fax:636-294-1566
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103362363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428953418Medicaid
MO500028069OtherRAILROAD MEDICARE
MO500028069OtherRAILROAD MEDICARE
MOS44363Medicare UPIN