Provider Demographics
NPI:1134211006
Name:ROETHKE, CAROL M (APN)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:M
Last Name:ROETHKE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19723-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4000
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1000 WHITE HORSE ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4406
Practice Address - Country:US
Practice Address - Phone:856-309-8508
Practice Address - Fax:856-309-8556
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNN07231100363LP0200X, 363L00000X
DEL10023808363LP0200X, 363L00000X
DELJ0000192363LP0200X, 363L00000X
NJNR07231100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q08928Medicare UPIN