Provider Demographics
NPI:1336919141
Name:ROTH, SANDRA NICOLE (RN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:NICOLE
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 1:979 ULSTER HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:ELLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12428-5746
Mailing Address - Country:US
Mailing Address - Phone:347-403-0477
Mailing Address - Fax:
Practice Address - Street 1:979 ULSTER HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:ELLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12428-5746
Practice Address - Country:US
Practice Address - Phone:347-403-0477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY834387-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse