Provider Demographics
NPI:1356397657
Name:ROBERTS, DERRETH C (ARNP)
Entity type:Individual
Prefix:
First Name:DERRETH
Middle Name:C
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ELIZABETH RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03908-2174
Mailing Address - Country:US
Mailing Address - Phone:603-740-2649
Mailing Address - Fax:
Practice Address - Street 1:789 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2526
Practice Address - Country:US
Practice Address - Phone:603-740-2697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH047079-23-05363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1000849Medicaid
S73386Medicare UPIN
NH1000849Medicaid