Provider Demographics
NPI:1184853715
Name:ROEDER, TENLEY JOY (NP)
Entity Type:Individual
Prefix:
First Name:TENLEY
Middle Name:JOY
Last Name:ROEDER
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 1:1136 E STUART ST STE 4101
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-1173
Mailing Address - Country:US
Mailing Address - Phone:970-833-1280
Mailing Address - Fax:949-437-2021
Practice Address - Street 1:1136 E STUART ST STE 4101
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1173
Practice Address - Country:US
Practice Address - Phone:970-833-1280
Practice Address - Fax:949-437-2021
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10022363LF0000X
COAPN.0010022-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF0709352OtherFNP CERTIFICATION
COCO305662Medicare PIN