Healthcare Provider Details

I. General information

NPI: 1710540505
Provider Name (Legal Business Name): KELLY ROSCHEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 HART BLVD STE 100
MONTICELLO MN
55362-8929
US

IV. Provider business mailing address

2605 BLUE RIDGE ROAD SUITE 100
RALEIGH NC
27607-6475
US

V. Phone/Fax

Practice location:
  • Phone: 763-682-1313
  • Fax: 763-581-9090
Mailing address:
  • Phone: 919-881-9009
  • Fax: 919-881-8463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number78062
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: