Provider Demographics
NPI:1063953784
Name:ROETHLE, MEGAN (CCP, RN)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:ROETHLE
Suffix:
Gender:F
Credentials:CCP, RN
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:K
Other - Last Name:JUSTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCP, RN
Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-355-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
242T00000X
WI196715163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
No163W00000XNursing Service ProvidersRegistered Nurse