Provider Demographics
NPI:1609150598
Name:ROBERTS, MARY JACQUELINE (APRN, FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JACQUELINE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9408
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1465 N GARDNER ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-7751
Practice Address - Country:US
Practice Address - Phone:812-752-0001
Practice Address - Fax:812-752-0010
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007173363LF0000X
IN71004757A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201050260Medicaid
KY7100186690Medicaid
IN71004757AOtherSTATE LICENSE