Provider Demographics
NPI:1629306451
Name:ROTHROCK, AMANDA EMBRY (CRNA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:EMBRY
Last Name:ROTHROCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:EMBRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:320 WHITTINGTON PKWY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4928
Mailing Address - Country:US
Mailing Address - Phone:502-690-8782
Mailing Address - Fax:502-365-2255
Practice Address - Street 1:320 WHITTINGTON PKWY
Practice Address - Street 2:SUITE 301
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4928
Practice Address - Country:US
Practice Address - Phone:502-690-8782
Practice Address - Fax:502-365-2255
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006324367500000X
KY1103759163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1103759OtherRN