Provider Demographics
NPI:1942613492
Name:ROBERTS, LISA GAYLE (RN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GAYLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 RALEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-2014
Mailing Address - Country:US
Mailing Address - Phone:757-515-1733
Mailing Address - Fax:
Practice Address - Street 1:620 JHN PAUL JNS CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:757-953-5752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI76606163W00000X
VA0001192223163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse