Provider Demographics
NPI:1386979664
Name:ROBERTS, TERRA W (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:TERRA
Middle Name:W
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:FNP-BC
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 148
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:KY
Mailing Address - Zip Code:42347-0148
Mailing Address - Country:US
Mailing Address - Phone:270-276-9953
Mailing Address - Fax:
Practice Address - Street 1:44 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FORDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42343-9761
Practice Address - Country:US
Practice Address - Phone:270-276-9953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100113740Medicaid
KY00438007Medicare PIN