Provider Demographics
NPI:1629093455
Name:ROBERTS, GWENITA (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:GWENITA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3436 S POLK ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75224-3804
Mailing Address - Country:US
Mailing Address - Phone:214-372-9200
Mailing Address - Fax:214-372-9201
Practice Address - Street 1:3436 S POLK ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-3804
Practice Address - Country:US
Practice Address - Phone:214-372-9200
Practice Address - Fax:214-372-9201
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX578285363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7149594OtherAETNA
TXNP7128OtherBLUE CROSS BLUE SHIELD
TX10008701Medicaid
TX12906Medicaid
TX562313709OtherUNITED HEALTHCARE
TX155741501Medicaid
TX155741502Medicaid
TX155741503Medicaid
TX8Y1837OtherBLUE CROSS BLUE SHIELD
TX562313709OtherUNITED HEALTHCARE
TXP92383Medicare UPIN
TX155741502Medicaid