Provider Demographics
NPI:1508882556
Name:ROTH, THERESA LYNNE (CRNA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNNE
Last Name:ROTH
Suffix:
Gender:F
Credentials:CRNA
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Mailing Address - Street 1:4135 BOARDMAN CANFIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9803
Mailing Address - Country:US
Mailing Address - Phone:330-286-5330
Mailing Address - Fax:330-286-5396
Practice Address - Street 1:200 E STATE ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4936
Practice Address - Country:US
Practice Address - Phone:330-286-5330
Practice Address - Fax:330-286-5396
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CRNA.02076367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0932361Medicaid
OHP02145866OtherMEDICARE RAILROAD PTAN