Provider Demographics
NPI:1578818936
Name:ROOSEVELT, LEE KIRSTIN (CNM)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:KIRSTIN
Last Name:ROOSEVELT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-5131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 PROFESSIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5131
Practice Address - Country:US
Practice Address - Phone:734-926-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704269336367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife