Provider Demographics
NPI:1194292854
Name:ROBERTS, MICHELLE LYNN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 SUNTIDES BLVD
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-9042
Mailing Address - Country:US
Mailing Address - Phone:509-985-4917
Mailing Address - Fax:
Practice Address - Street 1:120 S 3RD ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-2875
Practice Address - Country:US
Practice Address - Phone:509-248-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA608298732470A2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2470A2800XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health InformationAssistant Record Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-0755984Medicaid