Provider Demographics
NPI:1821803909
Name:ROATH, GRACIE JAE
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:JAE
Last Name:ROATH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 S AUBURN ST STE C2
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-4318
Mailing Address - Country:US
Mailing Address - Phone:530-889-7240
Mailing Address - Fax:
Practice Address - Street 1:760 S AUBURN ST STE C2
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-4318
Practice Address - Country:US
Practice Address - Phone:530-889-7240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-07
Last Update Date:2025-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOQP372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion