Provider Demographics
NPI:1912159781
Name:SMITH, ROBERTA (RN)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:ROBERTA
Other - Middle Name:ANN
Other - Last Name:FREELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:272 MEDICAL LOOP
Mailing Address - Street 2:SUITE E
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471
Mailing Address - Country:US
Mailing Address - Phone:541-440-3532
Mailing Address - Fax:541-440-3554
Practice Address - Street 1:2700 STEWART PARKWAY
Practice Address - Street 2:ANNEX B
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-440-3532
Practice Address - Fax:541-440-3554
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200040188RN163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500665845Medicaid