Provider Demographics
NPI:1891260105
Name:ROTH, LAURIE ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:ANN
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 1:331 N SHAFTER AVE
Mailing Address - Street 2:
Mailing Address - City:SHAFTER
Mailing Address - State:CA
Mailing Address - Zip Code:93263-1967
Mailing Address - Country:US
Mailing Address - Phone:661-746-8613
Mailing Address - Fax:661-746-8614
Practice Address - Street 1:331 N SHAFTER AVE
Practice Address - Street 2:
Practice Address - City:SHAFTER
Practice Address - State:CA
Practice Address - Zip Code:93263-1967
Practice Address - Country:US
Practice Address - Phone:661-746-8613
Practice Address - Fax:661-746-8614
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA431493163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool