Provider Demographics
NPI:1083133235
Name:ROTH, LISA HUGHES
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:HUGHES
Last Name:ROTH
Suffix:
Gender:F
Credentials:
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-3120
Mailing Address - Fax:239-343-4042
Practice Address - Street 1:501 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2618
Practice Address - Country:US
Practice Address - Phone:239-424-3120
Practice Address - Fax:239-424-1423
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4772133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121375300Medicaid