Provider Demographics
NPI:1871047308
Name:ROTH, ELISE (RN)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 SUNRISE CT
Mailing Address - Street 2:APT 13
Mailing Address - City:MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11955-2021
Mailing Address - Country:US
Mailing Address - Phone:631-560-7740
Mailing Address - Fax:
Practice Address - Street 1:73 SUNRISE CT
Practice Address - Street 2:APT 13
Practice Address - City:MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11955-2021
Practice Address - Country:US
Practice Address - Phone:631-560-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-13
Last Update Date:2016-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY720081-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse