Provider Demographics
NPI:1841736857
Name:ROTH, DIANA LYNETTE
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNETTE
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 LELAND LAKE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-2690
Mailing Address - Country:US
Mailing Address - Phone:217-883-0428
Mailing Address - Fax:
Practice Address - Street 1:640 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1350
Practice Address - Country:US
Practice Address - Phone:217-285-2113
Practice Address - Fax:217-285-2989
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015451363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily