Provider Demographics
NPI:1033731765
Name:ROE, CAMILLA LYNN (CNM)
Entity Type:Individual
Prefix:
First Name:CAMILLA
Middle Name:LYNN
Last Name:ROE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 S LAYTON BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-1925
Mailing Address - Country:US
Mailing Address - Phone:414-643-6454
Mailing Address - Fax:
Practice Address - Street 1:1502 S LAYTON BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-1925
Practice Address - Country:US
Practice Address - Phone:414-643-6454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI148999-32367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife