1194975466 NPI number — JOANNA BELLE ROTH M.S., A.C.N.P.-B.C.

Table of content: JOANNA BELLE ROTH M.S., A.C.N.P.-B.C. (NPI 1194975466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194975466 NPI number — JOANNA BELLE ROTH M.S., A.C.N.P.-B.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
JOANNA
Provider Middle Name:
BELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., A.C.N.P.-B.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194975466
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21764 OMEGA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOSHEN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46528-7809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-891-4920
Provider Business Mailing Address Fax Number:
574-891-4902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21764 OMEGA CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOSHEN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46528-7809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-891-4920
Provider Business Practice Location Address Fax Number:
574-891-4902
Provider Enumeration Date:
09/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2083B0002X , with the licence number:  71002933A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: 71002933A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 71002933A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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