Provider Demographics
NPI:1649423096
Name:ROBERTS, CAROL MARGARET
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:MARGARET
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:5811 CEDAR LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:952-544-6223
Mailing Address - Fax:952-544-6271
Practice Address - Street 1:5811 CEDAR LAKE ROAD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:952-544-6223
Practice Address - Fax:952-544-6271
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR091496-3305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization