MEDICARE: BARBARA LEE ROTH REGISTERED NURSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC1600X	Continuing Education/Staff Development Registered Nurse	549631	CA
2	163WI0600X	Infection Control Registered Nurse	549631	CA
3	163WP2201X	Ambulatory Care Registered Nurse	549631	CA
4	163W00000X	Registered Nurse	549631	CA

General Provider Information

NPI Number	:	1417669573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BARBARA LEE ROTH REGISTERED NURSE

Provider Business Mailing Address
First Line	:	4215 HAMILTON AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95130-1462
Country	:	US
Telephone Number	:	408-761-5847
Fax Number	:

Provider Business Practice Location Address
First Line	:	4215 HAMILTON AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95130-1462
Country	:	US
Telephone Number	:	408-761-5847
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2022
Last Update Date	:	12/20/2022

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