Provider Demographics
NPI:1811044233
Name:MICHELE ANN ROBERTS, PC
Entity Type:Organization
Organization Name:MICHELE ANN ROBERTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GERIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:GNP
Authorized Official - Phone:636-294-5735
Mailing Address - Street 1:6209 MID RIVERS MALL DR
Mailing Address - Street 2:#317
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63304-1102
Mailing Address - Country:US
Mailing Address - Phone:636-294-5735
Mailing Address - Fax:636-294-1566
Practice Address - Street 1:6209 MID RIVERS MALL DR
Practice Address - Street 2:#317
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63304-1102
Practice Address - Country:US
Practice Address - Phone:636-294-5735
Practice Address - Fax:636-294-1566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103362363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB9981OtherRR MEDICARE
DB9981OtherRR MEDICARE