Provider Demographics
NPI:1326099839
Name:ROEDER, KATHLEEN PATRICIA (CNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:PATRICIA
Last Name:ROEDER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3053 MACK RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5334
Mailing Address - Country:US
Mailing Address - Phone:513-682-7273
Mailing Address - Fax:513-682-7253
Practice Address - Street 1:3050 MACK RD
Practice Address - Street 2:SUITE 305
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5379
Practice Address - Country:US
Practice Address - Phone:513-682-7273
Practice Address - Fax:513-682-7253
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA08267NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRONP18421Medicare ID - Type Unspecified
OHQ45060Medicare UPIN