Provider Demographics
NPI:1710540505
Name:ROSCHEN, KELLY (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:ROSCHEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2605 BLUE RIDGE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6475
Mailing Address - Country:US
Mailing Address - Phone:919-881-9009
Mailing Address - Fax:919-881-8463
Practice Address - Street 1:1001 HART BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8929
Practice Address - Country:US
Practice Address - Phone:763-682-1313
Practice Address - Fax:763-581-9090
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
390200000X
MN78062208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program