Provider Demographics
NPI:1447206529
Name:RODERICK, ADDIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ADDIE
Middle Name:
Last Name:RODERICK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S DELAWARE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-6512
Mailing Address - Country:US
Mailing Address - Phone:480-646-1001
Mailing Address - Fax:480-646-1002
Practice Address - Street 1:105 S DELAWARE DR STE 2
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-6512
Practice Address - Country:US
Practice Address - Phone:480-646-1001
Practice Address - Fax:480-646-1002
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN6179363L00000X
AZAP3930363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP3930OtherLICENSE
KY78013760Medicaid
TN4087938OtherBLUECROSS
AZ653785Medicaid
AZ653785Medicaid
TN3905157Medicare PIN