Healthcare Provider Details

I. General information

NPI: 1942087010
Provider Name (Legal Business Name): ANDREA MARIE ROLTGEN CPM, LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2023
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17632 N ADVENT LN
HAUSER ID
83854-5431
US

IV. Provider business mailing address

17632 N ADVENT LN
HAUSER ID
83854-5431
US

V. Phone/Fax

Practice location:
  • Phone: 208-416-1701
  • Fax: 208-216-1433
Mailing address:
  • Phone: 208-416-1701
  • Fax: 208-216-1433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMID-149
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: