Provider Demographics
NPI:1417077223
Name:ROACH, KELLY LEE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LEE
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 1:173 W CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:44047-1380
Mailing Address - Country:US
Mailing Address - Phone:440-576-3066
Mailing Address - Fax:
Practice Address - Street 1:173 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:44047-1380
Practice Address - Country:US
Practice Address - Phone:440-576-3066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN . 109453164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2286253Medicaid