Provider Demographics
NPI:1760160634
Name:ROBERTS, LORENZO
Entity Type:Individual
Prefix:
First Name:LORENZO
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4764 NW COUNTY ROAD 141
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32053-3159
Mailing Address - Country:US
Mailing Address - Phone:202-740-2654
Mailing Address - Fax:
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATTAHOOCHEE
Practice Address - State:FL
Practice Address - Zip Code:32324-1198
Practice Address - Country:US
Practice Address - Phone:850-663-1046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11027002363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty