Provider Demographics
NPI:1568835742
Name:ROTH, STEFANIE MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:MARIE
Last Name:ROTH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:MARIE
Other - Last Name:BERNKLAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2946 N PARKDALE CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-6040
Mailing Address - Country:US
Mailing Address - Phone:316-215-4841
Mailing Address - Fax:
Practice Address - Street 1:7570 W 21ST ST N
Practice Address - Street 2:SUITE 1026 D
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1734
Practice Address - Country:US
Practice Address - Phone:316-729-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-93878163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health