Provider Demographics
NPI:1710739016
Name:ROBERTS, MINDY (RN)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 GEORGIA AVE SUITE 106
Mailing Address - Street 2:BOX #176
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841
Mailing Address - Country:US
Mailing Address - Phone:803-508-0125
Mailing Address - Fax:
Practice Address - Street 1:923 CURRYTOWNE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29860-8929
Practice Address - Country:US
Practice Address - Phone:803-508-0125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC215776163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse