Provider Demographics
NPI:1184459398
Name:ROTH, GRACE MARIE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:MARIE
Last Name: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 1:11400 APACHE DR APT 102
Mailing Address - Street 2:
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-9017
Mailing Address - Country:US
Mailing Address - Phone:216-225-9033
Mailing Address - Fax:
Practice Address - Street 1:11400 APACHE DR APT 102
Practice Address - Street 2:
Practice Address - City:PARMA HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-9017
Practice Address - Country:US
Practice Address - Phone:216-225-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide