Provider Demographics
NPI:1740646348
Name:ROBERTSON, RENATA (NP)
Entity type:Individual
Prefix:
First Name:RENATA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746092
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6092
Mailing Address - Country:US
Mailing Address - Phone:574-334-5400
Mailing Address - Fax:574-237-1348
Practice Address - Street 1:5340 HOLY CROSS PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1470
Practice Address - Country:US
Practice Address - Phone:800-860-8100
Practice Address - Fax:574-204-7792
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN28151749A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner