Healthcare Provider Details

I. General information

NPI: 1487022885
Provider Name (Legal Business Name): JOHN ROLL APRN,CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HIGHWAY 12
HETTINGER ND
58639-7530
US

IV. Provider business mailing address

PO BOX 2010
FARGO ND
58122-2484
US

V. Phone/Fax

Practice location:
  • Phone: 701-567-4561
  • Fax:
Mailing address:
  • Phone: 701-234-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberR36407
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: