Provider Demographics
NPI:1669652236
Name:ROTH, SUSAN C (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:ROTH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 GLENN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1200
Mailing Address - Country:US
Mailing Address - Phone:570-784-1723
Mailing Address - Fax:570-784-8512
Practice Address - Street 1:410 GLENN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1200
Practice Address - Country:US
Practice Address - Phone:570-784-1723
Practice Address - Fax:570-784-8512
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN240439L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101087458 0002Medicaid
PA100746682 0006Medicaid