Provider Demographics
NPI:1912597600
Name:ROTH, AMANDA (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:1130 W GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-2344
Mailing Address - Country:US
Mailing Address - Phone:920-750-0167
Mailing Address - Fax:
Practice Address - Street 1:1130 W GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-2344
Practice Address - Country:US
Practice Address - Phone:920-750-0167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI176224163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse