Provider Demographics
NPI:1821089376
Name:ROETMAN, KELLY A (APN)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:ROETMAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:973 MICA DR STE 201
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89705-7258
Mailing Address - Country:US
Mailing Address - Phone:775-783-6190
Mailing Address - Fax:775-783-6191
Practice Address - Street 1:973 MICA DR STE 201
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89705
Practice Address - Country:US
Practice Address - Phone:775-783-6190
Practice Address - Fax:775-783-6191
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA513594163W00000X
NV26083163W00000X
NVAPN000605363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCC9627OtherBCBS
NV1821089376Medicaid
NVCC9627OtherBCBS