Provider Demographics
NPI:1932683984
Name:ROBERTS, ASHLEY MICHELLE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MICHELLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-5015
Mailing Address - Country:US
Mailing Address - Phone:918-779-0709
Mailing Address - Fax:
Practice Address - Street 1:109 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447
Practice Address - Country:US
Practice Address - Phone:918-779-0709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-15
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103283363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily