Basic Information
Provider Information | |||||||||
NPI: | 1255895686 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | MARLENE | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD, FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 41ST ST | ||||||||
Address2: |   | ||||||||
City: | MANHATTAN BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 902663141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054532444 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2027 VILLAGE LN STE 102 | ||||||||
Address2: |   | ||||||||
City: | SOLVANG | ||||||||
State: | CA | ||||||||
PostalCode: | 934632271 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056817700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2019 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | F09181574 | CA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 363LF0000X | F09181574 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.