Provider Demographics
NPI:1518353390
Name:ROTH, KIM
Entity Type:Individual
Prefix:
First Name:KIM
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 1:3285 CYPRESS LEGENDS CIR APT 934
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-5537
Mailing Address - Country:US
Mailing Address - Phone:301-787-7783
Mailing Address - Fax:
Practice Address - Street 1:3285 CYPRESS LEGENDS CIR APT 934
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-5537
Practice Address - Country:US
Practice Address - Phone:301-787-7783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9365090163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL163W00000XOther163W00000X