Provider Demographics
NPI:1568619765
Name:ROTH, KRISTEN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 CAROL LN
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-8259
Mailing Address - Country:US
Mailing Address - Phone:440-365-5317
Mailing Address - Fax:
Practice Address - Street 1:715 CAROL LN
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-8259
Practice Address - Country:US
Practice Address - Phone:440-365-5317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.126595 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse