Provider Demographics
NPI:1669107892
Name:ROTH, AMANDA NICOLE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
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 1:703 MAJESTIC DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2254
Mailing Address - Country:US
Mailing Address - Phone:210-899-9568
Mailing Address - Fax:
Practice Address - Street 1:703 MAJESTIC DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2254
Practice Address - Country:US
Practice Address - Phone:210-899-9568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians