MEDICARE: SUSAN ROLLER GOEHL-MANOLIS APRN

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	363LW0102X	Women's Health Nurse Practitioner	NP1196272	MN
2	363LW0102X	Women's Health Nurse Practitioner	1428	MN
3	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	1428	MN

General Provider Information

NPI Number	:	1629201751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN ROLLER GOEHL-MANOLIS APRN

Provider Business Mailing Address
First Line	:	7525 MITCHELL RD STE 315
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-1958
Country	:	US
Telephone Number	:	952-300-3016
Fax Number	:	952-353-9635

Provider Business Practice Location Address
First Line	:	7525 MITCHELL RD STE 315
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-1958
Country	:	US
Telephone Number	:	952-300-3016
Fax Number	:	952-353-9635

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

Provider Enumeration Date	:	08/24/2009
Last Update Date	:	01/07/2026

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