Provider Demographics
NPI:1629785605
Name:ROBERTSN, DONIQUE BRENT (LPN)
Entity Type:Individual
Prefix:
First Name:DONIQUE
Middle Name:BRENT
Last Name:ROBERTSN
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 1:263 NORTHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14208-1228
Mailing Address - Country:US
Mailing Address - Phone:716-517-8112
Mailing Address - Fax:
Practice Address - Street 1:263 NORTHLAND AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14208-1228
Practice Address - Country:US
Practice Address - Phone:716-517-8112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335202-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse