Provider Demographics
NPI:1790481711
Name:ROBERTS, MAGGIE ELIZABETH (MEDICAL ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:MAGGIE
Middle Name:ELIZABETH
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MEDICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 W MAIN ST STE 27
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3700
Mailing Address - Country:US
Mailing Address - Phone:618-213-7133
Mailing Address - Fax:
Practice Address - Street 1:6500 W MAIN ST STE 27
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3700
Practice Address - Country:US
Practice Address - Phone:618-213-7133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3002239251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health