Provider Demographics
NPI:1093424780
Name:ROTH, LAURA (RN, IBCLC)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25255 CABOT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5507
Mailing Address - Country:US
Mailing Address - Phone:949-698-9000
Mailing Address - Fax:
Practice Address - Street 1:25255 CABOT RD STE 101
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5507
Practice Address - Country:US
Practice Address - Phone:949-698-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA654381163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1427779719Medicaid