Provider Demographics
NPI:1639337009
Name:ROACH, KATIE G (ANP)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:G
Last Name:ROACH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 MOTLEY RD
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:SC
Mailing Address - Zip Code:29061-9635
Mailing Address - Country:US
Mailing Address - Phone:803-776-6342
Mailing Address - Fax:
Practice Address - Street 1:1819 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6907
Practice Address - Country:US
Practice Address - Phone:803-434-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC949363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0000OtherDO NOT HAVE MEDICAID OR MEDICARE ID #