Provider Demographics
NPI:1942684253
Name:BOON, ROBERTA (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:
Last Name:BOON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MRS
Other - First Name:ROBERTA
Other - Middle Name:BROWNING
Other - Last Name:BOON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:PO BOX 1625
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1625
Mailing Address - Country:US
Mailing Address - Phone:928-645-9675
Mailing Address - Fax:928-645-2626
Practice Address - Street 1:2016 W 16TH ST
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4026
Practice Address - Country:US
Practice Address - Phone:928-428-1500
Practice Address - Fax:928-428-1555
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1091692163WG0000X, 363LF0000X
AZAP8216363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ087936Medicaid
AZZ184049Medicare PIN
AZZ184050Medicare PIN