Provider Demographics
NPI:1417669573
Name:ROTH, BARBARA LEE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:LEE
Last Name:ROTH
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95130-1462
Mailing Address - Country:US
Mailing Address - Phone:408-761-5847
Mailing Address - Fax:
Practice Address - Street 1:4215 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95130-1462
Practice Address - Country:US
Practice Address - Phone:408-761-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA549631163WC1600X, 163WI0600X, 163WP2201X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WI0600XNursing Service ProvidersRegistered NurseInfection Control
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care