Basic Information
| Provider Information | |||||||||
| NPI: | 1063588853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLLER | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DNP, ANP-C (ANP-BC) | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROLLER | ||||||||
| OtherFirstName: | MAUREEN | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DNP, ANP-BC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 206 GLEN COVE AVE | ||||||||
| Address2: | |||||||||
| City: | SEA CLIFF | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166761742 | ||||||||
| FaxNumber: | 5166769662 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 GLEN COVE AVE | ||||||||
| Address2: | |||||||||
| City: | SEA CLIFF | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166761742 | ||||||||
| FaxNumber: | 5166769662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2006 | ||||||||
| LastUpdateDate: | 05/01/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 303280 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.