Provider Demographics
NPI:1508341728
Name:ROBERTS, MISTY ANN
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:ANN
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 1:103 E EDGEBROOK DR APT 4004
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77034-1476
Mailing Address - Country:US
Mailing Address - Phone:832-276-7076
Mailing Address - Fax:
Practice Address - Street 1:103 E EDGEBROOK DR APT 4004
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77034-1476
Practice Address - Country:US
Practice Address - Phone:832-276-7076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201088164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse