Provider Demographics
NPI:1467157297
Name:ROTH, KERRIE SHEA (NP)
Entity Type:Individual
Prefix:MRS
First Name:KERRIE
Middle Name:SHEA
Last Name:ROTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KERRIE
Other - Middle Name:SHEA
Other - Last Name:CAHALIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2015 ORINOCO DR
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-2515
Mailing Address - Country:US
Mailing Address - Phone:631-645-5633
Mailing Address - Fax:
Practice Address - Street 1:1991 MARCUS AVE STE M100
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2062
Practice Address - Country:US
Practice Address - Phone:631-645-5633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350446363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily