Provider Demographics
NPI:1164094843
Name:ROTH, MARY EILEEN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:EILEEN
Last Name:ROTH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:EILEEN
Other - Last Name:GERARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5044 EISENHOWER AVE APT 418
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-4869
Mailing Address - Country:US
Mailing Address - Phone:804-658-8536
Mailing Address - Fax:
Practice Address - Street 1:6100 ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-2901
Practice Address - Country:US
Practice Address - Phone:703-237-8627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182085363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily