Provider Demographics
NPI:1245291152
Name:ROTH, KATHRINE D (NP)
Entity type:Individual
Prefix:
First Name:KATHRINE
Middle Name:D
Last Name:ROTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-1113
Mailing Address - Country:US
Mailing Address - Phone:608-882-4761
Mailing Address - Fax:
Practice Address - Street 1:120 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1113
Practice Address - Country:US
Practice Address - Phone:608-882-4761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI570363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner