Provider Demographics
NPI:1164548103
Name:LOTH, ELAINE (PNP)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:LOTH
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 W MARCH LN
Mailing Address - Street 2:STE #1
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5721
Mailing Address - Country:US
Mailing Address - Phone:209-478-2622
Mailing Address - Fax:
Practice Address - Street 1:89 W MARCH LN
Practice Address - Street 2:STE #1
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5721
Practice Address - Country:US
Practice Address - Phone:209-478-2622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN557498363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN557498OtherRN LICENSE
CANP12548OtherFURNISHING LICENSE