Provider Demographics
NPI:1780149856
Name:ROBERTS, AMY (LVN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 WELLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051
Mailing Address - Country:US
Mailing Address - Phone:806-928-8516
Mailing Address - Fax:
Practice Address - Street 1:1906 WELLINGTON DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-3739
Practice Address - Country:US
Practice Address - Phone:806-928-8516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341885164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse