MEDICARE: MRS. ALISA MARIE ROTH RN

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	163WH0200X	Home Health Registered Nurse	417086	OH

General Provider Information

NPI Number	:	1649482555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALISA MARIE ROTH RN

Provider Business Mailing Address
First Line	:	PO BOX 122
Second Line	:
City	:	GNADENHUTTEN
State	:	OH
Zip	:	44629-0122
Country	:	US
Telephone Number	:	330-204-9855
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 122
Second Line	:
City	:	GNADENHUTTEN
State	:	OH
Zip	:	44629-0122
Country	:	US
Telephone Number	:	330-204-9855
Fax Number	:

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

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	03/11/2026

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