Basic Information
| Provider Information | |||||||||
| NPI: | 1083133235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | HUGHES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12550 NEW BRITTANY BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339073655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439267 | ||||||||
| FaxNumber: | 2393439268 | ||||||||
| Practice Location | |||||||||
| Address1: | 12550 NEW BRITTANY BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339073655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394243120 | ||||||||
| FaxNumber: | 2394241423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2017 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | ND4772 | FL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.