Provider Demographics
NPI:1083878508
Name:ROTH, TERRY L (RN)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:L
Last Name:ROTH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 E QUAIL WOOD LN
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-9038
Mailing Address - Country:US
Mailing Address - Phone:317-867-3318
Mailing Address - Fax:
Practice Address - Street 1:304 E QUAIL WOOD LN
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-9038
Practice Address - Country:US
Practice Address - Phone:317-867-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28182642A163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine