Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | XOO4297 | NY |
NPI | 1538145644 |
---|---|
Provider Name | Judith G Roth |
First Address | Lido Beach, NY 11561-4840 |
Second Address | Lido Beach, NY 11561-4840 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2005 |
Last Update Date | 20/05/2008 |