Provider Demographics
NPI:1023066446
Name:ROBERTS, MICHELLE JEAN (FNP, PMHNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JEAN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 NW RALEIGH ST. SUITE 211 / MBX 410
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1753
Mailing Address - Country:US
Mailing Address - Phone:971-282-2346
Mailing Address - Fax:971-228-1382
Practice Address - Street 1:1722 NW RALEIGH ST. SUITE 211 / MBX 410
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1753
Practice Address - Country:US
Practice Address - Phone:971-282-2346
Practice Address - Fax:971-228-1382
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200550161NP363LF0000X
OR201250209NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily