Provider Demographics
NPI:1376978262
Name:ROACH, TONYA M (CRNP)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:M
Last Name:ROACH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:TONAY
Other - Middle Name:M
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:251 N BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36603-5827
Mailing Address - Country:US
Mailing Address - Phone:251-690-8158
Mailing Address - Fax:251-544-2188
Practice Address - Street 1:251 N BAYOU ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36603-5827
Practice Address - Country:US
Practice Address - Phone:251-690-8158
Practice Address - Fax:251-544-2188
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-106985363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1063439065OtherNPI GROUP PAYEE NUMBER
AL630000013Medicaid
AL011846OtherMEDICARE GROUP PAYEE NUMBER