Provider Demographics
NPI:1063716215
Name:ROUSSET, MARY K (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:ROUSSET
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36665 ROAD P.3
Mailing Address - Street 2:
Mailing Address - City:MANCOS
Mailing Address - State:CO
Mailing Address - Zip Code:81328-8748
Mailing Address - Country:US
Mailing Address - Phone:970-882-4750
Mailing Address - Fax:
Practice Address - Street 1:1345 S BROADWAY
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-9505
Practice Address - Country:US
Practice Address - Phone:970-565-4400
Practice Address - Fax:970-565-9543
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONP 1692363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health