Provider Demographics
NPI:1659336139
Name:BENNETT ROLL, KATHERINE M (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:BENNETT ROLL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LINDEN OAKS
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2841
Mailing Address - Country:US
Mailing Address - Phone:585-248-9170
Mailing Address - Fax:
Practice Address - Street 1:10 HAGEN DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2660
Practice Address - Country:US
Practice Address - Phone:585-267-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY458423367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA5876Medicare PIN