Provider Demographics
NPI:1104382910
Name:ROACH, KRISTEN A (LPN)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:A
Last Name:ROACH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 E 21ST ST APT 25
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-7286
Mailing Address - Country:US
Mailing Address - Phone:570-350-5320
Mailing Address - Fax:
Practice Address - Street 1:636 E 21ST ST APT 25
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-7286
Practice Address - Country:US
Practice Address - Phone:570-350-5320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-17
Last Update Date:2019-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324863-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty