Provider Demographics
NPI:1134765043
Name:ROATH, MEGHAN LYNN
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:LYNN
Last Name:ROATH
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 1:421 N INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1617
Mailing Address - Country:US
Mailing Address - Phone:309-202-7976
Mailing Address - Fax:
Practice Address - Street 1:421 N INDIANA AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-1617
Practice Address - Country:US
Practice Address - Phone:309-202-7976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider