Provider Demographics
NPI:1780225011
Name:ROTH, ROBERTA LAURENE
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:LAURENE
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ROBERTA
Other - Middle Name:LAURENE
Other - Last Name:MANKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1501 SAN PEDRO SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider