Provider Demographics
NPI:1275820599
Name:ROACH, STEPHANIE RENEE (FNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:ROACH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4842
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-4842
Mailing Address - Country:US
Mailing Address - Phone:423-247-7030
Mailing Address - Fax:423-247-7033
Practice Address - Street 1:2020 BROOKSIDE DR
Practice Address - Street 2:SUITE 20
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4633
Practice Address - Country:US
Practice Address - Phone:423-247-7030
Practice Address - Fax:423-247-7033
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15751363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily