Provider Demographics
NPI:1518468958
Name:ROTH, ROBYN RAE (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:RAE
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 1:3908 HORSEPEN MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-1126
Mailing Address - Country:US
Mailing Address - Phone:540-470-0968
Mailing Address - Fax:
Practice Address - Street 1:1906 BELLEVIEW AVE SE, 12TH FLOOR SOUTH TOWER
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-853-0215
Practice Address - Fax:540-342-0913
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001171825163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant