Provider Demographics
NPI:1225172505
Name:ROETHKE, COLLEEN MARIE (RN)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:ROETHKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13908 JAMES AVE S
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4456
Mailing Address - Country:US
Mailing Address - Phone:952-403-2609
Mailing Address - Fax:952-403-3806
Practice Address - Street 1:1455 SAINT FRANCIS AVE
Practice Address - Street 2:DIABETES EDUCATION PROGRAM
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3374
Practice Address - Country:US
Practice Address - Phone:952-403-2609
Practice Address - Fax:952-403-3806
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 103484-2163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator