Healthcare Provider Details

I. General information

NPI: 1558433227
Provider Name (Legal Business Name): TRICIA ANN ROESLER LRD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 ELM STREET
LISBON ND
58054
US

IV. Provider business mailing address

15302 52 1/2 ST SE
LEONARD ND
58052-9201
US

V. Phone/Fax

Practice location:
  • Phone: 701-683-5823
  • Fax: 701-683-0034
Mailing address:
  • Phone: 701-645-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number691
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: