Provider Demographics
NPI:1215015375
Name:ROTH SHARP, LISA ELLEN (DC)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ELLEN
Last Name:ROTH SHARP
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:100 LAFAYETTE STREET
Mailing Address - City:ROSENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:54974-0051
Mailing Address - Country:US
Mailing Address - Phone:920-872-2969
Mailing Address - Fax:
Practice Address - Street 1:100 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:ROSENDALE
Practice Address - State:WI
Practice Address - Zip Code:54974-9661
Practice Address - Country:US
Practice Address - Phone:920-872-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2012-05-10
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-09-12
Provider Licenses
StateLicense IDTaxonomies
WI2604111N00000X
WI2604012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor