Provider Demographics
NPI:1154951093
Name:ROUSSEL, CARY MARTHA (RN)
Entity type:Individual
Prefix:
First Name:CARY
Middle Name:MARTHA
Last Name:ROUSSEL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14201 XENON ST NW UNIT 11
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2977
Mailing Address - Country:US
Mailing Address - Phone:763-227-3388
Mailing Address - Fax:
Practice Address - Street 1:500 W MAIN ST STE 11
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2000
Practice Address - Country:US
Practice Address - Phone:763-753-8658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR152982-3163WH0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FEMALEOtherRN
NAOtherNA