Healthcare Provider Details

I. General information

NPI: 1891330726
Provider Name (Legal Business Name): SARAH ROTH AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 LANDMARK DR STE B
LAFAYETTE IN
47905-6652
US

IV. Provider business mailing address

3750 LANDMARK DR STE B
LAFAYETTE IN
47905-6652
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax:
Mailing address:
  • Phone: 765-448-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number28210194A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: