Provider Demographics
NPI:1437281375
Name:ROACH, MARY SUSAN (FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SUSAN
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 470
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-0470
Mailing Address - Country:US
Mailing Address - Phone:208-634-2174
Mailing Address - Fax:
Practice Address - Street 1:703 N. 1ST STREET
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3851
Practice Address - Country:US
Practice Address - Phone:208-630-8002
Practice Address - Fax:208-634-2174
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP 87-A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily