Provider Demographics
NPI:1811661705
Name:ROBERTSON, NICOLE DEANN (CNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DEANN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10313 LOS ARBOLES AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1518
Mailing Address - Country:US
Mailing Address - Phone:505-948-8045
Mailing Address - Fax:
Practice Address - Street 1:201 CEDAR ST SE STE 505
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4925
Practice Address - Country:US
Practice Address - Phone:505-764-9535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM63450363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily