Provider Demographics
NPI:1881796035
Name:ROBERTS, NIKISHA NICOLE (MPH PAC)
Entity type:Individual
Prefix:MRS
First Name:NIKISHA
Middle Name:NICOLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MPH PAC
Other - Prefix:MS
Other - First Name:NIKISHA
Other - Middle Name:NICOLE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPH PAC
Mailing Address - Street 1:1989 W LUMSDEN RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8821
Mailing Address - Country:US
Mailing Address - Phone:813-653-3111
Mailing Address - Fax:813-653-1384
Practice Address - Street 1:1989 W LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8821
Practice Address - Country:US
Practice Address - Phone:813-653-3111
Practice Address - Fax:813-653-1384
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102619363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101660400Medicaid