Provider Demographics
NPI:1477757136
Name:ROBERTS, MARY K (ACNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:214-590-4105
Mailing Address - Fax:214-590-4162
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:MEDICAL AFFAIRS
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-8006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX519874363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y2002OtherBLUE CROSS BLUE SHIELD
8J8260Medicare PIN