Provider Demographics
NPI:1497094866
Name:ROBERTS, AMY KELLY (APRN)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:KELLY
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 FERN CIR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3517
Mailing Address - Country:US
Mailing Address - Phone:203-676-2939
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DRIVE
Practice Address - Street 2:88 MDG
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5171
Practice Address - Country:US
Practice Address - Phone:203-676-2939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5377363LP0808X
CT094283390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health