Provider Demographics
NPI:1467893289
Name:ROTH, KATHRYN JILL (FNP-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JILL
Last Name:ROTH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 FLANDRO DR
Mailing Address - Street 2:STE 110
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4936
Mailing Address - Country:US
Mailing Address - Phone:208-242-3723
Mailing Address - Fax:208-904-1052
Practice Address - Street 1:1800 FLANDRO DR
Practice Address - Street 2:STE 110
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-4936
Practice Address - Country:US
Practice Address - Phone:208-904-1544
Practice Address - Fax:208-904-1052
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1287A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily