Provider Demographics
NPI:1790016301
Name:MOFFITT, ROBIN D (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:ROBIN
Middle Name:D
Last Name:MOFFITT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:D
Other - Last Name:KESSLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1717 E CHICAGO RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-8524
Mailing Address - Country:US
Mailing Address - Phone:269-651-4744
Mailing Address - Fax:
Practice Address - Street 1:1717 E CHICAGO RD
Practice Address - Street 2:SUITE 2
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-8524
Practice Address - Country:US
Practice Address - Phone:269-651-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704246809363LF0000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1790016301Medicaid
MI1790016301Medicaid
MI722001394Medicare PIN