Provider Demographics
NPI:1447810189
Name:ROBERTSON, ERICA NICOLE
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:NICOLE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3557
Mailing Address - Country:US
Mailing Address - Phone:731-882-8716
Mailing Address - Fax:
Practice Address - Street 1:1807 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3557
Practice Address - Country:US
Practice Address - Phone:731-882-8716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-15
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X
TNL000000026537376J00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker