Provider Demographics
NPI:1508366402
Name:ROBERTS, SERENA DAWN
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:DAWN
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 1:18275 N 59TH AVE
Mailing Address - Street 2:STE 138
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1253
Mailing Address - Country:US
Mailing Address - Phone:602-564-0078
Mailing Address - Fax:602-564-1154
Practice Address - Street 1:17500 N 67TH AVE APT 1043
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1081
Practice Address - Country:US
Practice Address - Phone:480-620-6435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10959363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily