Individual
MELINDA M ROTH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PMHNP
Contact information
Practice address
3144 VANZILE RD, CRANDON, WI 54520-8149
(715) 478-5180
(715) 478-5904
Mailing address
1100 BEECH ST BLDG 10, NORMAL, IL 61761-1493
(309) 463-5800
(833) 914-2704
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
209010719
IL
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
277000959
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
35957000
—
WI
01
—
783333
PROVIDER STATE LICENSE
WI
Enumeration date
09/24/2013
Last updated
09/01/2022
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