Provider Demographics
NPI:1982431482
Name:ROBERTS, RAYSHAYNA ROSE
Entity type:Individual
Prefix:
First Name:RAYSHAYNA
Middle Name:ROSE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
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 120
Mailing Address - Street 2:
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671-0120
Mailing Address - Country:US
Mailing Address - Phone:218-214-3849
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 114
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671-0114
Practice Address - Country:US
Practice Address - Phone:218-679-1538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker