Provider Demographics
NPI:1417557984
Name:ROACH, CAMMIE L
Entity Type:Individual
Prefix:
First Name:CAMMIE
Middle Name:L
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-8380
Mailing Address - Country:US
Mailing Address - Phone:304-721-9148
Mailing Address - Fax:
Practice Address - Street 1:1029 PINE ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-8380
Practice Address - Country:US
Practice Address - Phone:304-721-9148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant