Provider Demographics
NPI:1992347462
Name:ROSKYDOLL, CASEY
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:ROSKYDOLL
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 1:13861 RACEWAY DR APT 732
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-6557
Mailing Address - Country:US
Mailing Address - Phone:682-429-6272
Mailing Address - Fax:
Practice Address - Street 1:13861 RACEWAY DR APT 732
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76262-6557
Practice Address - Country:US
Practice Address - Phone:682-429-6272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314253164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse