Provider Demographics
NPI:1760250088
Name:ROBERTSON, KATHRYN MICAELA (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:MICAELA
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1154 S THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5605
Mailing Address - Country:US
Mailing Address - Phone:166-232-2702
Mailing Address - Fax:
Practice Address - Street 1:1154 S THOMAS ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5605
Practice Address - Country:US
Practice Address - Phone:166-232-2702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906332363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner