Provider Demographics
NPI:1780132852
Name:WORTHAM-FLORENCE, ROOSEVELT HEZEKIAH (NP)
Entity type:Individual
Prefix:MR
First Name:ROOSEVELT
Middle Name:HEZEKIAH
Last Name:WORTHAM-FLORENCE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6545 MARKET AVE N STE 100
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-2430
Mailing Address - Country:US
Mailing Address - Phone:937-516-3030
Mailing Address - Fax:
Practice Address - Street 1:1800 DAYOH PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-4318
Practice Address - Country:US
Practice Address - Phone:937-668-3097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
311ZA0620X
OHAPRN.CNP.0029130363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home