Provider Demographics
NPI:1942087010
Name:ROLTGEN, ANDREA MARIE (CPM, LM)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MARIE
Last Name:ROLTGEN
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17632 N ADVENT LN
Mailing Address - Street 2:
Mailing Address - City:HAUSER
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5431
Mailing Address - Country:US
Mailing Address - Phone:208-416-1701
Mailing Address - Fax:208-216-1433
Practice Address - Street 1:17632 N ADVENT LN
Practice Address - Street 2:
Practice Address - City:HAUSER
Practice Address - State:ID
Practice Address - Zip Code:83854-5431
Practice Address - Country:US
Practice Address - Phone:208-416-1701
Practice Address - Fax:208-216-1433
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMID-149176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife