MEDICARE: MONICA MICHELE ROADRUCK NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LX0106X	Occupational Health Nurse Practitioner	71008438A	IN

General Provider Information

NPI Number	:	1053886788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONICA MICHELE ROADRUCK NP

Provider Business Mailing Address
First Line	:	760 PARK EAST BLVD
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-0795
Country	:	US
Telephone Number	:	765-447-7473
Fax Number	:	765-449-8504

Provider Business Practice Location Address
First Line	:	3218 DAUGHERTY DR STE 140
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47909-3997
Country	:	US
Telephone Number	:	765-502-4190
Fax Number	:	765-502-4191

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2018
Last Update Date	:	12/09/2019

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