Provider Demographics
NPI:1487743571
Name:ROBERTS, ALICE J (FNP)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:J
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 1:904 TROY MILL RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27020-7265
Mailing Address - Country:US
Mailing Address - Phone:704-539-4086
Mailing Address - Fax:
Practice Address - Street 1:757 BRYANT ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4142
Practice Address - Country:US
Practice Address - Phone:704-873-5658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0001132012363LF0000X
NC5004976363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0001743447OtherBCBS
WV3810004033Medicaid
WV3810004033Medicaid
WV2026855Medicare PIN
WV0001743447OtherBCBS
WVQ46216Medicare UPIN
WV2026852Medicare PIN
WV2026851Medicare PIN