Provider Demographics
NPI:1699196659
Name:ROBERTS, PHYLLIS (R N)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:R N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 W PICACHO AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-4823
Mailing Address - Country:US
Mailing Address - Phone:575-527-5884
Mailing Address - Fax:575-527-5886
Practice Address - Street 1:4501 W PICACHO AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007-4823
Practice Address - Country:US
Practice Address - Phone:575-527-9606
Practice Address - Fax:575-527-9612
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR18834163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool