Provider Demographics
NPI:1114283207
Name:RODERICK, ANNE (MSN PMHNP)
Entity Type:Individual
Prefix:MS
First Name:ANNE
Middle Name:
Last Name:RODERICK
Suffix:
Gender:F
Credentials:MSN PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WEST 16 STREET
Mailing Address - Street 2:8HN
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011
Mailing Address - Country:US
Mailing Address - Phone:212-255-0540
Mailing Address - Fax:
Practice Address - Street 1:115 BROADWAY
Practice Address - Street 2:SUITE 1300
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006
Practice Address - Country:US
Practice Address - Phone:212-233-2830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF4012691363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health