Provider Demographics
NPI:1023614641
Name:ROBERTSON, LORETTA SULUDA
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:SULUDA
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 1:207 CARDINAL RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1161
Mailing Address - Country:US
Mailing Address - Phone:404-217-8711
Mailing Address - Fax:
Practice Address - Street 1:CROSSROADS TREATMENT CENTER OF DANVILLE PC
Practice Address - Street 2:1555 MEADOWVIEW DRIVE
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541
Practice Address - Country:US
Practice Address - Phone:434-685-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN133863163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice