Healthcare Provider Details

I. General information

NPI: 1780132852
Provider Name (Legal Business Name): ROOSEVELT HEZEKIAH WORTHAM-FLORENCE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2016
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 CLARETT CT
UNION OH
45322-3545
US

IV. Provider business mailing address

6545 MARKET AVE N STE 100
CANTON OH
44721-2430
US

V. Phone/Fax

Practice location:
  • Phone: 937-321-0002
  • Fax:
Mailing address:
  • Phone: 937-321-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0029130
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: