Provider Demographics
NPI:1154757045
Name:ROTH, MELINDA M (PMHNP)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:M
Last Name:ROTH
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 BEECH ST BLDG 10
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1493
Mailing Address - Country:US
Mailing Address - Phone:309-463-5800
Mailing Address - Fax:833-914-2704
Practice Address - Street 1:3144 VANZILE RD
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-8149
Practice Address - Country:US
Practice Address - Phone:715-478-5180
Practice Address - Fax:715-478-5904
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010719363LF0000X
IL277000959363LP0808X
IL041337908163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI783333OtherPROVIDER STATE LICENSE
WI35957000Medicaid