Provider Demographics
NPI:1558643775
Name:ROACH, KIMBERLY B (RN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:B
Last Name:ROACH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 DAYSPRING RDG
Mailing Address - Street 2:
Mailing Address - City:WALWORTH
Mailing Address - State:NY
Mailing Address - Zip Code:14568-9517
Mailing Address - Country:US
Mailing Address - Phone:315-986-3521
Mailing Address - Fax:315-986-1716
Practice Address - Street 1:1500 DAYSPRING RDG
Practice Address - Street 2:
Practice Address - City:WALWORTH
Practice Address - State:NY
Practice Address - Zip Code:14568-9517
Practice Address - Country:US
Practice Address - Phone:315-986-3521
Practice Address - Fax:315-986-1716
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY451138-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse