Provider Demographics
NPI:1487004750
Name:BUENAFLOR-ROTH, GENEROSA
Entity Type:Individual
Prefix:
First Name:GENEROSA
Middle Name:
Last Name:BUENAFLOR-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 1:713 WINSLOW ST
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:CA
Mailing Address - Zip Code:94525-1253
Mailing Address - Country:US
Mailing Address - Phone:510-932-0909
Mailing Address - Fax:
Practice Address - Street 1:713 WINSLOW ST
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:CA
Practice Address - Zip Code:94525-1253
Practice Address - Country:US
Practice Address - Phone:510-932-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA548307163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse