Provider Demographics
NPI:1922003169
Name:ROBERTS, LILLY IDA (APN)
Entity Type:Individual
Prefix:
First Name:LILLY
Middle Name:IDA
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1060
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:AR
Mailing Address - Zip Code:72650-1060
Mailing Address - Country:US
Mailing Address - Phone:870-448-5733
Mailing Address - Fax:870-448-5736
Practice Address - Street 1:322 DOGWOOD HOLLOW RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560-8626
Practice Address - Country:US
Practice Address - Phone:870-269-2995
Practice Address - Fax:870-269-2991
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01186 ANP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP000014273OtherRAILROAD MEDICARE
AR54041B477OtherBLUECROSS OF ARKANSAS
ARS61922Medicare UPIN