Provider Demographics
NPI:1831829068
Name:ROTH, RENEE ANN (NP)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:ANN
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 1:2699 NE LAWTON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:KS
Mailing Address - Zip Code:66725-2078
Mailing Address - Country:US
Mailing Address - Phone:620-762-1081
Mailing Address - Fax:
Practice Address - Street 1:915 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:KS
Practice Address - Zip Code:66725-1508
Practice Address - Country:US
Practice Address - Phone:471-310-9286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-11
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-150198-022163W00000X
KS53-82256-022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse