Provider Demographics
NPI:1285072751
Name:ROBERTS, REBECCA A (APRN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 737
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41314-0737
Mailing Address - Country:US
Mailing Address - Phone:606-593-6023
Mailing Address - Fax:606-593-6087
Practice Address - Street 1:86 HIGHWAY 638
Practice Address - Street 2:SUITE 1
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-7289
Practice Address - Country:US
Practice Address - Phone:606-596-0701
Practice Address - Fax:606-596-0703
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008071363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100258650Medicaid
KYK096351Medicare PIN
KYK096350Medicare PIN