Provider Demographics
NPI:1144993684
Name:ROBERTS, PRISCILLA CAROL (RN)
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:CAROL
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3022 OLD MINDEN RD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-2477
Mailing Address - Country:US
Mailing Address - Phone:318-525-7741
Mailing Address - Fax:
Practice Address - Street 1:3022 OLD MINDEN RD STE 100
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-2454
Practice Address - Country:US
Practice Address - Phone:318-741-7314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN143288163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse