Provider Demographics
NPI:1467451708
Name:ROBERTS, MICHELE (GNP)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 323
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63022-0323
Mailing Address - Country:US
Mailing Address - Phone:314-289-6655
Mailing Address - Fax:
Practice Address - Street 1:368 WESTGLEN VILLAGE DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-6134
Practice Address - Country:US
Practice Address - Phone:366-289-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103362363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428953418Medicaid
MO500028069OtherRAILROAD MEDICARE
MO500028069OtherRAILROAD MEDICARE
MOS44363Medicare UPIN