Provider Demographics
NPI:1831710581
Name:ROBERTS, LEEANN RACHELLE (NP)
Entity type:Individual
Prefix:
First Name:LEEANN
Middle Name:RACHELLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:NP
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 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:5921 W STATE ROAD 46
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-9359
Practice Address - Country:US
Practice Address - Phone:812-935-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28216246A363LF0000X
KY3014858363LF0000X
IL209.022118363LF0000X
IN71010017A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100668200Medicaid
KYPDZ000000500406OtherAETNA BETTER HEALTH OF KENTUCKY PROVIDER ID NUMBER
7427472OtherUNITED HEALTHCARE PROVIDER ID NUMBER
KY2234405OtherWELLCARE OF KENTUCKY PROVIDER ID NUMBER
284847OtherSIHO PROVIDER ID NUMBER
IN300037929Medicaid
6246517OtherAETNA PROVIDER ID NUMBER
000001373756OtherANTHEM PROVIDER ID NUMBER
KY3014858OtherSTATE LICENSE
CS2020500316OtherCARESOURCE PROVIDER ID NUMBER