Provider Demographics
NPI:1568737716
Name:ROEDER, NICOLE LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LYNN
Last Name:ROEDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BOURNIVAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:560 S MAPLE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1757
Mailing Address - Country:US
Mailing Address - Phone:603-264-1335
Mailing Address - Fax:
Practice Address - Street 1:560 S MAPLE ST STE 400
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1757
Practice Address - Country:US
Practice Address - Phone:952-442-2191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2022-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN63495207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program