Provider Demographics
NPI:1528490398
Name:ROBERTSON, D. SUSIE (APRN-BC)
Entity type:Individual
Prefix:
First Name:D. SUSIE
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 N GLENSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-2130
Mailing Address - Country:US
Mailing Address - Phone:417-832-1167
Mailing Address - Fax:417-832-1193
Practice Address - Street 1:1308 N GLENSTONE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-2130
Practice Address - Country:US
Practice Address - Phone:417-832-1167
Practice Address - Fax:417-832-1193
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013029017363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily