Provider Demographics
NPI:1649405978
Name:ROACH, BEONKA PAULETTE (RN)
Entity Type:Individual
Prefix:MRS
First Name:BEONKA
Middle Name:PAULETTE
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 1:1725 S BUCKEYE ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-2144
Mailing Address - Country:US
Mailing Address - Phone:765-854-1413
Mailing Address - Fax:
Practice Address - Street 1:1725 S BUCKEYE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-2144
Practice Address - Country:US
Practice Address - Phone:765-854-1413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28137902A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse