Provider Demographics
NPI:1528217445
Name:ROBERTS, ANDREA (LPN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 S 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-2264
Mailing Address - Country:US
Mailing Address - Phone:623-772-5110
Mailing Address - Fax:623-772-5120
Practice Address - Street 1:45 S 3RD AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-2264
Practice Address - Country:US
Practice Address - Phone:623-772-5110
Practice Address - Fax:623-772-5120
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP039220164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse