Healthcare Provider Details

I. General information

NPI: 1295975266
Provider Name (Legal Business Name): RENEE L ROTH CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 EXCHANGE STREET
ASTORIA OR
97103
US

IV. Provider business mailing address

2111 EXCHANGE ST
ASTORIA OR
97103-3329
US

V. Phone/Fax

Practice location:
  • Phone: 503-338-4085
  • Fax: 503-338-4086
Mailing address:
  • Phone: 503-325-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10027557
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: