Provider Demographics
NPI:1861965352
Name:ROBERTS, SUSAN LEE (CNM, WHNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CNM, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-967-8625
Mailing Address - Fax:310-423-0140
Practice Address - Street 1:8635 W 3RD ST STE 160W
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6103
Practice Address - Country:US
Practice Address - Phone:310-967-8625
Practice Address - Fax:310-423-0140
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010328363LX0001X
CA235992176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA483840OtherRN
CA95010328OtherWHNP
CA235992OtherCNM