Healthcare Provider Details

I. General information

NPI: 1043563463
Provider Name (Legal Business Name): TRACY ANN ROEHL APRN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIR # 2300 CENTRACARE CLINIC HEALTH PLAZA OBSTETRICS AND WOMEN'S H
SAINT CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRACARE CIR # 2300 CENTRACARE CLINIC HEALTH PLAZA OBSTETRICS AND WOMEN'S H
SAINT CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-654-3630
  • Fax: 320-654-3657
Mailing address:
  • Phone: 320-654-3630
  • Fax: 320-654-3657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR184825-8
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF1012160
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP0403
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: