Provider Demographics
NPI:1295392330
Name:DE JESUS-ROETLIN, NICOLE ERIN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ERIN
Last Name:DE JESUS-ROETLIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:WELLMAN
Mailing Address - State:IA
Mailing Address - Zip Code:52356-4707
Mailing Address - Country:US
Mailing Address - Phone:319-646-3388
Mailing Address - Fax:
Practice Address - Street 1:600 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2235
Practice Address - Country:US
Practice Address - Phone:361-881-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No174H00000XOther Service ProvidersHealth Educator