Healthcare Provider Details

I. General information

NPI: 1679977185
Provider Name (Legal Business Name): JENNIFER M ROTH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST BLOOMBERG 7308
BALTIMORE MD
21287-2101
US

IV. Provider business mailing address

1800 ORLEANS ST BLOOMBERG 7308
BALTIMORE MD
21287-2101
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-2914
  • Fax:
Mailing address:
  • Phone: 410-955-2914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR150450
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: