Provider Demographics
NPI:1619034592
Name:ROTH, SANDRA ELAINE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:ELAINE
Last Name:ROTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:701 N MONTICELLO ST
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-1138
Mailing Address - Country:US
Mailing Address - Phone:574-946-4315
Mailing Address - Fax:574-542-2996
Practice Address - Street 1:6194 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:IN
Practice Address - Zip Code:46960-9297
Practice Address - Country:US
Practice Address - Phone:574-542-2552
Practice Address - Fax:574-542-2996
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7100817A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP15354Medicare UPIN