Basic Information
Provider Information | |||||||||
NPI: | 1891780193 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | TERI | ||||||||
MiddleName: | LYN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OSTERKAMP | ||||||||
OtherFirstName: | TERI | ||||||||
OtherMiddleName: | LYN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APRN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 234 MEDICAL CIR STE 1 | ||||||||
Address2: |   | ||||||||
City: | MOREHEAD | ||||||||
State: | KY | ||||||||
PostalCode: | 403511194 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6067846641 | ||||||||
FaxNumber: | 6067802373 | ||||||||
Practice Location | |||||||||
Address1: | 234 MEDICAL CIR STE 1 | ||||||||
Address2: |   | ||||||||
City: | MOREHEAD | ||||||||
State: | KY | ||||||||
PostalCode: | 403511194 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6067846641 | ||||||||
FaxNumber: | 6067802373 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2005 | ||||||||
LastUpdateDate: | 04/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A-071191 | IA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3010007 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 3010007 | 01 | KY | KY MEDICAL LICENSE | OTHER |