Provider Demographics
NPI:1619123478
Name:ROBERTS, REBECCA L (CNP,CDE)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CNP,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SUGAR CAMP CIR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:OAKWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1963
Mailing Address - Country:US
Mailing Address - Phone:937-395-3656
Mailing Address - Fax:937-395-3657
Practice Address - Street 1:136 S LUDLOW ST
Practice Address - Street 2:FL. 1
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-1813
Practice Address - Country:US
Practice Address - Phone:937-499-8273
Practice Address - Fax:937-223-9811
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH291690163W00000X
OHNP-10474363LF0000X
OHRN291690163WD0400X
OHCOA.10474-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000599279OtherBCBS OHIO
OH2948341Medicaid
OH421534506138OtherCARESOURCE OHIO
OH421534506138OtherCARESOURCE OHIO