Provider Demographics
NPI:1649876376
Name:ROTH, LISA J
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22249 JONATHAN DR
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44149-2045
Mailing Address - Country:US
Mailing Address - Phone:440-503-0360
Mailing Address - Fax:
Practice Address - Street 1:9560 COVE DR
Practice Address - Street 2:
Practice Address - City:N ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-2756
Practice Address - Country:US
Practice Address - Phone:440-237-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide