Individual
CAROLYN ROTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
N.P.
Contact information
Practice address
1701 E COLLEGE AVE, BLOOMINGTON, IL 61704-2101
(309) 664-3038
Mailing address
1701 E COLLEGE AVE, BLOOMINGTON, IL 61704-2101
(309) 664-3000
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
209000155
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
IL2613
MEDICARE GROUP PTAN
IL
Enumeration date
02/26/2007
Last updated
11/20/2009
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