Provider Demographics
NPI:1518461540
Name:ROACH, CHRISANNE GENNILLE (MD)
Entity Type:Individual
Prefix:
First Name:CHRISANNE
Middle Name:GENNILLE
Last Name:ROACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1874 BLUE JAY PT
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-9711
Mailing Address - Country:US
Mailing Address - Phone:786-202-1796
Mailing Address - Fax:
Practice Address - Street 1:781 AVENT FERRY RD STE 106
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-7776
Practice Address - Country:US
Practice Address - Phone:919-567-6133
Practice Address - Fax:919-567-6134
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2022-00998207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program