Provider Demographics
NPI:1871066324
Name:ROTH, EMILY JEAN
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:JEAN
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15410 FORTUNA BAY DR UNIT 3003
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-6385
Mailing Address - Country:US
Mailing Address - Phone:361-813-5886
Mailing Address - Fax:
Practice Address - Street 1:4444 CORONA DR STE 107
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4374
Practice Address - Country:US
Practice Address - Phone:361-400-1886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX956339164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse