Provider Demographics
NPI:1730458571
Name:RODERER, BETHANY (CRNP)
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:
Last Name:RODERER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8813 MAYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-5024
Mailing Address - Country:US
Mailing Address - Phone:240-535-1569
Mailing Address - Fax:
Practice Address - Street 1:8813 MAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-5024
Practice Address - Country:US
Practice Address - Phone:240-535-1569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR142576363L00000X
MECNP141003363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MR3104027OtherDEA