Provider Demographics
NPI:1255399283
Name:ROLLIE, CHARLOTTE ANN (FNP, CNM)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:ANN
Last Name:ROLLIE
Suffix:
Gender:F
Credentials:FNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:218-732-2800
Mailing Address - Fax:218-732-2874
Practice Address - Street 1:705 PLEASANT AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470
Practice Address - Country:US
Practice Address - Phone:218-732-2800
Practice Address - Fax:218-732-2874
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1203026363LF0000X
MNCNP0022367A00000X
MNCNM0006367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1255399283Medicaid
MNP23641Medicare UPIN
MN420001255Medicare PIN