Provider Demographics
NPI:1811625239
Name:ROTH, CHELSEA (FNP)
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CHELSEA
Other - Middle Name:
Other - Last Name:HACKING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2458 W 630 N
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-4855
Mailing Address - Country:US
Mailing Address - Phone:435-630-4100
Mailing Address - Fax:
Practice Address - Street 1:150 W 100 N # N-101
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2036
Practice Address - Country:US
Practice Address - Phone:435-781-6300
Practice Address - Fax:435-781-6301
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8202085-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner