Provider Demographics
NPI:1275004210
Name:ROACH, NICOLE BROOK (PTA, LMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:BROOK
Last Name:ROACH
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 BUEHRLE DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-1926
Mailing Address - Country:US
Mailing Address - Phone:573-462-0853
Mailing Address - Fax:
Practice Address - Street 1:1720 VIETH DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2056
Practice Address - Country:US
Practice Address - Phone:573-635-6139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018037409225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant