Provider Demographics
NPI:1295048700
Name:ROTH, TINA L (LPN)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:ROTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 E HIGHLAND AVE # 3135
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5266
Mailing Address - Country:US
Mailing Address - Phone:208-353-4209
Mailing Address - Fax:
Practice Address - Street 1:2321 E HIGHLAND AVE # 3135
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5266
Practice Address - Country:US
Practice Address - Phone:208-353-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP046575164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse