Healthcare Provider Details

I. General information

NPI: 1821089376
Provider Name (Legal Business Name): KELLY A ROETMAN APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

973 MICA DR STE 201
CARSON CITY NV
89705
US

IV. Provider business mailing address

973 MICA DR STE 201
CARSON CITY NV
89705-7258
US

V. Phone/Fax

Practice location:
  • Phone: 775-783-6190
  • Fax: 775-783-6191
Mailing address:
  • Phone: 775-783-6190
  • Fax: 775-783-6191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN000605
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number513594
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26083
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: