Provider Demographics
NPI:1508004763
Name:ROBERTSON, DOROTHY SUE (FNP)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:SUE
Last Name:ROBERTSON
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 1:7947 SAN GORGONIO ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-3919
Mailing Address - Country:US
Mailing Address - Phone:909-899-3062
Mailing Address - Fax:
Practice Address - Street 1:182 E WALNUT AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-3530
Practice Address - Country:US
Practice Address - Phone:909-820-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA507554163WG0000X
CA16423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice