Provider Demographics
NPI:1235188558
Name:ROLLER, CYDNEY (NP)
Entity Type:Individual
Prefix:
First Name:CYDNEY
Middle Name:
Last Name:ROLLER
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 1:400 N PENNSYLVANIA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4754
Mailing Address - Country:US
Mailing Address - Phone:575-623-9101
Mailing Address - Fax:575-623-3020
Practice Address - Street 1:400 N PENNSYLVANIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4754
Practice Address - Country:US
Practice Address - Phone:575-623-9101
Practice Address - Fax:575-623-3020
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP01000363LF0000X
NMR43142207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM50808338Medicaid