Healthcare Provider Details

I. General information

NPI: 1548302292
Provider Name (Legal Business Name): CLARICE ROTH ANP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LOWER LEVEL REYNOLDS GYM-WINGATE ROAD WINGATE ROAD
WINSTON-SALEM NC
27109
US

IV. Provider business mailing address

PO BOX 398
GERMANTON NC
27019-0398
US

V. Phone/Fax

Practice location:
  • Phone: 336-758-5218
  • Fax: 336-758-6054
Mailing address:
  • Phone: 336-591-7351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number21960
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: