Healthcare Provider Details

I. General information

NPI: 1417669573
Provider Name (Legal Business Name): BARBARA LEE ROTH REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 12/20/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 HAMILTON AVE
SAN JOSE CA
95130-1462
US

IV. Provider business mailing address

4215 HAMILTON AVE
SAN JOSE CA
95130-1462
US

V. Phone/Fax

Practice location:
  • Phone: 408-761-5847
  • Fax:
Mailing address:
  • Phone: 408-761-5847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number549631
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WI0600X
TaxonomyInfection Control Registered Nurse
License Number549631
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number549631
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number549631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: