Provider Demographics
NPI:1235958620
Name:ROTH, SANDRA LEE (RN)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LEE
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 1:2500 CENTENNIAL RD LOT 266
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0719
Mailing Address - Country:US
Mailing Address - Phone:701-226-8248
Mailing Address - Fax:
Practice Address - Street 1:2500 CENTENNIAL RD LOT 266
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0719
Practice Address - Country:US
Practice Address - Phone:701-226-8248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR232463747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant