Provider Demographics
NPI:1376775452
Name:ROESCHLAU, RUTH BARBARA (RN,PHN)
Entity Type:Individual
Prefix:MS
First Name:RUTH
Middle Name:BARBARA
Last Name:ROESCHLAU
Suffix:
Gender:F
Credentials:RN,PHN
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 27
Mailing Address - Street 2:
Mailing Address - City:CASSEL
Mailing Address - State:CA
Mailing Address - Zip Code:96016-0027
Mailing Address - Country:US
Mailing Address - Phone:530-335-5882
Mailing Address - Fax:
Practice Address - Street 1:36977 PARK AVE
Practice Address - Street 2:
Practice Address - City:BURNEY
Practice Address - State:CA
Practice Address - Zip Code:96013-4067
Practice Address - Country:US
Practice Address - Phone:530-335-3651
Practice Address - Fax:530-335-5241
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96824163W00000X
CA10151364SC1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHN10151Medicaid
CARN96824Medicaid