Provider Demographics
NPI:1649482555
Name:ROTH, ALISA MARIE (RN)
Entity type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:MARIE
Last Name:ROTH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-1017
Mailing Address - Country:US
Mailing Address - Phone:330-204-9855
Mailing Address - Fax:
Practice Address - Street 1:590 CALDERSBURGH ST
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-1000
Practice Address - Country:US
Practice Address - Phone:740-502-2907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-089999164W00000X
OH417086163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse