Provider Demographics
NPI:1619479011
Name:ROBERTS, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
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 1:1191 MEADOW LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-8230
Mailing Address - Country:US
Mailing Address - Phone:321-258-8006
Mailing Address - Fax:
Practice Address - Street 1:1071 PORT MALABAR BLVD NE STE 106
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5161
Practice Address - Country:US
Practice Address - Phone:407-720-8887
Practice Address - Fax:321-821-6860
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator