Healthcare Provider Details

I. General information

NPI: 1467618785
Provider Name (Legal Business Name): MARY A ROTH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 SOUTH 65 HIGHWAY
MARSHALL MO
65340-3702
US

IV. Provider business mailing address

2301 SOUTH 65 HIGHWAY
MARSHALL MO
65340-3702
US

V. Phone/Fax

Practice location:
  • Phone: 660-886-7800
  • Fax: 660-886-3328
Mailing address:
  • Phone: 660-886-7800
  • Fax: 660-831-3328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number149803
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: