MEDICARE: KELLI ROTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	352922	NY

General Provider Information

NPI Number	:	1023898244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI ROTH

Provider Business Mailing Address
First Line	:	60 W 23RD ST APT 549
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10010-5285
Country	:	US
Telephone Number	:	908-303-0801
Fax Number	:

Provider Business Practice Location Address
First Line	:	1041 47TH AVE
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5416
Country	:	US
Telephone Number	:	212-385-3700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2023
Last Update Date	:	10/04/2023

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Directions to “ KELLI ROTH ” Practice Location

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