Provider Demographics
NPI:1467638627
Name:ROBERTS, NICOLETTE RONAYE
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:RONAYE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 POKEGAMA AVE N
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744
Mailing Address - Country:US
Mailing Address - Phone:218-326-9453
Mailing Address - Fax:218-326-9453
Practice Address - Street 1:218 POKEGAMA AVE N
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-326-9453
Practice Address - Fax:218-326-9453
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20050045225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
20050045OtherAMMA