Basic Information
| Provider Information | |||||||||
| NPI: | 1134211006 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROETHKE | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREENE | ||||||||
| OtherFirstName: | CAROL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | |||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197230191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514000 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 WHITE HORSE ROAD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080434406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563098508 | ||||||||
| FaxNumber: | 8563098556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 10/10/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | NN07231100 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | L10023808 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | LJ0000192 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363L00000X | L10023808 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | LJ0000192 | DE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | NN07231100 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | NR07231100 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.