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General NPI Number Information
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NPI Number | 1700259173
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Entity Type | Organization
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Legal Business Name | CROSSROADS HEALTH & COSMETIC CENTER PC
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Dates
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Enumeration Date | 11/07/2015
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Last Update Date | 09/09/2019
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Provider Practice Location Address
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Address Line | 21764 OMEGA CT
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City | GOSHEN
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State | IN
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Zip | 46528-7809
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Country | US
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Telephone | 574-891-4920
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Fax | 574-891-4902
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Provider Business Mailing Address
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Address Line | 21764 OMEGA CT
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City | GOSHEN
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State | IN
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Zip | 46528-7809
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Country | US
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Telephone | 574-891-4920
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Fax | 574-891-4902
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | JOANNA ROTH
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Credential | ACNP-BC, FNP-C
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Telephone | 574-891-4920
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 71002933A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 71002933A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 71002933A
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License Number State | IN
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