Healthcare Provider Details

I. General information

NPI: 1790916864
Provider Name (Legal Business Name): DIANE ROTH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 08/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-2700
  • Fax: 314-268-2798
Mailing address:
  • Phone: 314-268-2700
  • Fax: 314-268-2798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number066206
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: