Provider Demographics
NPI:1942225214
Name:ANDERSON, ROBERTA L (CNP)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 METROHEALTH DR
Mailing Address - Street 2:MHMC-PEDIATRICS
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1900
Mailing Address - Country:US
Mailing Address - Phone:216-778-5427
Mailing Address - Fax:
Practice Address - Street 1:2500 METROHEALTH DR
Practice Address - Street 2:MHMC-PEDIATRICS
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1900
Practice Address - Country:US
Practice Address - Phone:216-778-5427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP01630363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2091712Medicaid
OH2091712Medicaid
OHANNP75321Medicare ID - Type Unspecified