Provider Demographics
NPI:1528372752
Name:ROBERSON, JAN MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:MARIE
Last Name:ROBERSON
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:PO BOX 2850
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85132-3053
Mailing Address - Country:US
Mailing Address - Phone:520-866-3500
Mailing Address - Fax:520-868-0798
Practice Address - Street 1:1000 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132-8132
Practice Address - Country:US
Practice Address - Phone:520-866-3500
Practice Address - Fax:520-868-0798
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP043322164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse