Provider Demographics
NPI:1447896568
Name:ROBERTS, MAYORY (APRN)
Entity type:Individual
Prefix:
First Name:MAYORY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:APRN
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 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-5333
Practice Address - Street 1:1828 165TH ST STE A
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-2823
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-844-9006
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH025912363LF0000X
IN71010982A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty