Healthcare Provider Details

I. General information

NPI: 1588740880
Provider Name (Legal Business Name): SUSAN ROGGEN TANKE CNM, NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2006
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 PELHAM PARKWAY SOUTH BUILDING 1 3 WEST 7
BRONX NY
10461
US

IV. Provider business mailing address

1400 PELHAM PARKWAY SOUTH BUILDING 1 3 WEST 7
BRONX NY
10461
US

V. Phone/Fax

Practice location:
  • Phone: 718-918-5446
  • Fax: 718-918-6787
Mailing address:
  • Phone: 718-918-5446
  • Fax: 718-918-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberF000783
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberF420555
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: