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General NPI Number Information
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NPI Number | 1154757045
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Entity Type | Individual
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Provider Name | MELINDA M ROTH PMHNP
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Gender | Female
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Dates
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Enumeration Date | 09/24/2013
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Last Update Date | 09/01/2022
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Provider Practice Location Address
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Address Line | 3144 VANZILE RD
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City | CRANDON
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State | WI
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Zip | 54520-8149
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Country | US
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Telephone | 715-478-5180
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Fax | 715-478-5904
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Provider Business Mailing Address
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Address Line | 1100 BEECH ST BLDG 10
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City | NORMAL
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State | IL
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Zip | 61761-1493
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Country | US
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Telephone | 309-463-5800
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Fax | 833-914-2704
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209010719
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 277000959
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License Number State | IL
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