Provider Demographics
NPI:1912783895
Name:MARTEL-ROUSSEAU, EMILIE
Entity type:Individual
Prefix:
First Name:EMILIE
Middle Name:
Last Name:MARTEL-ROUSSEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9049
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-9049
Mailing Address - Country:US
Mailing Address - Phone:303-415-4246
Mailing Address - Fax:303-415-8407
Practice Address - Street 1:2101 KEN PRATT BLVD STE 104G
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6568
Practice Address - Country:US
Practice Address - Phone:303-415-4246
Practice Address - Fax:303-415-8407
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60810574163W00000X
COC-APN.0102280-C-APN363L00000X
COC-APN.0102280-C-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner