Provider Demographics
NPI:1558576561
Name:ROTH, LISA M (RNC NNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:ROTH
Suffix:
Gender:F
Credentials:RNC NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 HOLLY HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-3134
Mailing Address - Country:US
Mailing Address - Phone:314-752-4327
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO066591363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care