Provider Demographics
NPI:1881677383
Name:ROBERTS, AMY LYNNE (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNNE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYNNE
Other - Last Name:QUERTERMUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:451 HEALTH PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-8242
Mailing Address - Country:US
Mailing Address - Phone:269-655-3065
Mailing Address - Fax:269-655-0588
Practice Address - Street 1:451 HEALTH PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-8242
Practice Address - Country:US
Practice Address - Phone:269-655-3065
Practice Address - Fax:269-655-0588
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704205287363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4939773Medicaid
MI500H010410OtherBCBSM
MIM97850013Medicare PIN