Provider Demographics
NPI:1750510533
Name:ROULEAU, KELLY THEO (PA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:THEO
Last Name:ROULEAU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:155 BORTHWICK AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7156
Mailing Address - Country:US
Mailing Address - Phone:978-691-5690
Mailing Address - Fax:603-410-4679
Practice Address - Street 1:155 BORTHWICK AVE STE 201
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801
Practice Address - Country:US
Practice Address - Phone:978-691-5690
Practice Address - Fax:603-410-4679
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEPA1660363A00000X
NH0734363A00000X, 363AM0700X, 363AS0400X
MAPA3778363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical