Provider Demographics
NPI:1154490704
Name:RODAK, COLLEEN MARY (NP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
Last Name:RODAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889-0004
Mailing Address - Country:US
Mailing Address - Phone:301-295-8723
Mailing Address - Fax:301-319-8240
Practice Address - Street 1:8901 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0004
Practice Address - Country:US
Practice Address - Phone:301-295-8723
Practice Address - Fax:301-319-8240
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN63680363L00000X, 363LA2100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC037921200Medicaid
DC019400M83Medicare ID - Type Unspecified
DC037921200Medicaid