Provider Demographics
NPI:1972158624
Name:ROBERTS, NICOLE ANN (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3003 HWAY 95 STE 102
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7802
Mailing Address - Country:US
Mailing Address - Phone:928-299-5333
Mailing Address - Fax:928-299-5336
Practice Address - Street 1:3003 HWAY 95 STE 102
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7802
Practice Address - Country:US
Practice Address - Phone:928-299-5333
Practice Address - Fax:928-299-5333
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012386363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily