Basic Information
| Provider Information | |||||||||
| NPI: | 1619123478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CNP,CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 SUGAR CAMP CIR | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | OAKWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454091963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373953656 | ||||||||
| FaxNumber: | 9373953657 | ||||||||
| Practice Location | |||||||||
| Address1: | 136 S LUDLOW ST | ||||||||
| Address2: | FL. 1 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454021813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374998273 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 09/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 291690 | OH | N | Nursing Service Providers | Registered Nurse | 363LF0000X | NP-10474 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WD0400X | RN291690 | OH | N | Nursing Service Providers | Registered Nurse | Diabetes Educator | 363LA2200X | COA.10474-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 000000599279 | 01 | OH | BCBS OHIO | OTHER | 2948341 | 05 | OH | MEDICAID | 421534506138 | 01 | OH | CARESOURCE OHIO | OTHER |