Provider Demographics
NPI:1881288264
Name:ROBERTS, LEQUITA
Entity type:Individual
Prefix:
First Name:LEQUITA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 VIRGINIA BEACH BLVD STE 8B
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-5621
Mailing Address - Country:US
Mailing Address - Phone:757-270-2924
Mailing Address - Fax:
Practice Address - Street 1:3320 VIRGINIA BEACH BLVD STE 8B
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-5621
Practice Address - Country:US
Practice Address - Phone:757-270-2924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-212486251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4568234912Medicaid