Provider Demographics
NPI:1689780629
Name:ROBERTS, LAURIE (CNM)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18300 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2206
Mailing Address - Country:US
Mailing Address - Phone:760-242-2311
Mailing Address - Fax:760-946-8875
Practice Address - Street 1:18077 US HIGHWAY 18
Practice Address - Street 2:SUITE 100
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2150
Practice Address - Country:US
Practice Address - Phone:760-946-8799
Practice Address - Fax:760-946-8875
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW1225367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANMW012250OtherMEDI-CAL