Provider Demographics
NPI:1114201118
Name:ROACH, SEMONE SABRINA (APRN)
Entity Type:Individual
Prefix:
First Name:SEMONE
Middle Name:SABRINA
Last Name:ROACH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1162 NEW BRITAIN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-2410
Mailing Address - Country:US
Mailing Address - Phone:860-236-3084
Mailing Address - Fax:860-561-5961
Practice Address - Street 1:1162 NEW BRITAIN AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-2410
Practice Address - Country:US
Practice Address - Phone:860-236-3084
Practice Address - Fax:860-561-5961
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004767363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP4428347OtherOXFORD-UNITED HEALTHCARE
CT008034903Medicaid