Provider Demographics
NPI:1992410468
Name:ROTH, ELYSSA LYNN (CNP)
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:LYNN
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 1:18906 BEBB ST
Mailing Address - Street 2:
Mailing Address - City:VENEDOCIA
Mailing Address - State:OH
Mailing Address - Zip Code:45894-9646
Mailing Address - Country:US
Mailing Address - Phone:567-644-5847
Mailing Address - Fax:
Practice Address - Street 1:2195 ALLENTOWN RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-1705
Practice Address - Country:US
Practice Address - Phone:419-227-2245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.463288163WE0003X
OHAPRN.CNP.0033090363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WE0003XNursing Service ProvidersRegistered NurseEmergency