Provider Demographics
NPI:1154535136
Name:ROBERSON, LORRAINE SUSAN (NP)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:SUSAN
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LORRAINE
Other - Middle Name:SUSAN
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:24425 PERIWINKLE WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2733
Mailing Address - Country:US
Mailing Address - Phone:951-275-3704
Mailing Address - Fax:
Practice Address - Street 1:9939 MAGNOLIA AVE STE C
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3528
Practice Address - Country:US
Practice Address - Phone:951-354-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17087363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health