Provider Demographics
NPI:1013332006
Name:ROBERSON, MARY COLLEEN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:COLLEEN
Last Name:ROBERSON
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 1:272 CHAMBERLIN DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14210-2614
Mailing Address - Country:US
Mailing Address - Phone:716-446-3715
Mailing Address - Fax:
Practice Address - Street 1:272 CHAMBERLIN DR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-2614
Practice Address - Country:US
Practice Address - Phone:716-446-3715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16300000X163W00000X, 163WA0400X, 163WC1500X, 163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator