Provider Demographics
NPI:1730460437
Name:ROBERTS, LANI MICHELLE
Entity Type:Individual
Prefix:
First Name:LANI
Middle Name:MICHELLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2694 OLD ROCKMART RD SE
Mailing Address - Street 2:
Mailing Address - City:SILVER CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30173-3125
Mailing Address - Country:US
Mailing Address - Phone:678-361-6926
Mailing Address - Fax:
Practice Address - Street 1:304 TURNER MCCALL BLVD SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5621
Practice Address - Country:US
Practice Address - Phone:706-509-6885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006220367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant