Provider Demographics
NPI:1295975266
Name:ROTH, RENEE L (CNP)
Entity type:Individual
Prefix:MS
First Name:RENEE
Middle Name:L
Last Name:ROTH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6680 POE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2855
Mailing Address - Country:US
Mailing Address - Phone:937-280-8400
Mailing Address - Fax:937-280-8373
Practice Address - Street 1:8881 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1333
Practice Address - Country:US
Practice Address - Phone:937-293-1622
Practice Address - Fax:937-245-6308
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA10617NP364SA2100X
OHAPRN.CNP.10617363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000611757OtherANTHEM
OH2983802Medicaid
OH2983802Medicaid