Provider Demographics
NPI:1184277444
Name:ROTH, KATELYN MARIE (MSN APRN AGCNS-BC)
Entity type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:MARIE
Last Name:ROTH
Suffix:
Gender:F
Credentials:MSN APRN AGCNS-BC
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:MARIE
Other - Last Name:DEPOLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1114 LINDEN ST BLDG 1
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-3045
Mailing Address - Country:US
Mailing Address - Phone:763-438-3544
Mailing Address - Fax:
Practice Address - Street 1:1500 RED RIVER ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1918
Practice Address - Country:US
Practice Address - Phone:512-324-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30810364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health