Healthcare Provider Details

I. General information

NPI: 1679135115
Provider Name (Legal Business Name): ELIZABETH SUZANNE BOTT CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 STATE ROUTE 44
ROOTSTOWN OH
44272-9733
US

IV. Provider business mailing address

4211 STATE ROUTE 44 STE 150
ROOTSTOWN OH
44272-9733
US

V. Phone/Fax

Practice location:
  • Phone: 234-867-7550
  • Fax: 234-867-7545
Mailing address:
  • Phone: 234-857-7550
  • Fax: 234-867-7545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.344221
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.025156
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: