Provider Demographics
NPI:1255851242
Name:ROTH, KATY
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:
Last Name:ROTH
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 1:830 PEACHERS MILL RD
Mailing Address - Street 2:APT M149
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-8448
Mailing Address - Country:US
Mailing Address - Phone:419-332-6697
Mailing Address - Fax:
Practice Address - Street 1:735 NORTH DR
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-2620
Practice Address - Country:US
Practice Address - Phone:270-886-5163
Practice Address - Fax:270-886-0392
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program