Provider Demographics
NPI:1669855615
Name:ROTH, LARISSA ANN (CNP)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:ANN
Last Name:ROTH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1003
Mailing Address - Country:US
Mailing Address - Phone:330-744-2118
Mailing Address - Fax:330-744-2110
Practice Address - Street 1:1001 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1003
Practice Address - Country:US
Practice Address - Phone:330-744-2118
Practice Address - Fax:330-744-2110
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.17618363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0137805Medicaid
OH0137805Medicaid