Provider Demographics
NPI:1720525447
Name:ROELKE, THERESA (NP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:ROELKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:FISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:100 CAMPUS DR
Practice Address - Street 2:SUITE 121
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7171
Practice Address - Country:US
Practice Address - Phone:207-396-7760
Practice Address - Fax:207-396-8500
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP161163363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400374725Medicare PIN