MEDICARE: JACQUELINE L ROETHLISBERGER NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	RN 199132 COA	OH
2	363LA2200X	Adult Health Nurse Practitioner	COA 03334 NP	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366561870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE L ROETHLISBERGER NP

Provider Business Mailing Address
First Line	:	1 PRESTIGE PL STE 550
Second Line	:
City	:	MIAMISBURG
State	:	OH
Zip	:	45342-6115
Country	:	US
Telephone Number	:	937-762-1310
Fax Number	:	937-522-8068

Provider Business Practice Location Address
First Line	:	3700 SOUTHERN BLVD STE 201
Second Line	:
City	:	KETTERING
State	:	OH
Zip	:	45429-1265
Country	:	US
Telephone Number	:	855-500-2873
Fax Number	:	937-281-3992

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	04/12/2022

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