Provider Demographics
NPI:1548480890
Name:ROBERTS, LINDA SHODD (CNM)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:SHODD
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PENDLETON ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2219
Mailing Address - Country:US
Mailing Address - Phone:918-457-7515
Mailing Address - Fax:918-456-7108
Practice Address - Street 1:1500 E DOWNING ST
Practice Address - Street 2:SUITE 208
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3234
Practice Address - Country:US
Practice Address - Phone:918-446-2496
Practice Address - Fax:918-456-7108
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0059260367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR00559260OtherOK NURSING LICENSE
OK200308880AMedicaid
OK731622831OtherTIN