Provider Demographics
NPI:1619422136
Name:ROBERTS, SUSAN O (FNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:O
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:FNP
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 932958
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-2454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:189 BROOKLAWN ST
Practice Address - Street 2:
Practice Address - City:FARRAGUT
Practice Address - State:TN
Practice Address - Zip Code:37934-2875
Practice Address - Country:US
Practice Address - Phone:865-392-9136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000021691363LF0000X
TNAPN21691363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ024785Medicaid
TNQ024785Medicaid