Provider Demographics
NPI:1306941158
Name:ROBERTSON, CAROLYN (APRN)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:ROBERTSON
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 1:2355 N PYRITE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-2509
Mailing Address - Country:US
Mailing Address - Phone:480-357-0018
Mailing Address - Fax:
Practice Address - Street 1:11601 WILSHIRE BLVD
Practice Address - Street 2:5TH FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-0509
Practice Address - Country:US
Practice Address - Phone:516-834-0564
Practice Address - Fax:646-843-4764
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214530163WM0705X, 163WD0400X, 364SM0705X
CA2753364SM0705X
CA704002163W00000X, 163WD0400X
AZRN1555154163W00000X
AZAP3296364SM0705X
NJNC99530364SM0705X
NJNR 99530163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR06032Medicare PIN
NYP39615Medicare UPIN