Provider Demographics
NPI:1750653663
Name:ROACH, DENISE JEAN (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:JEAN
Last Name:ROACH
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 /267 PORT RICHMOND AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302
Mailing Address - Country:US
Mailing Address - Phone:718-981-8117
Mailing Address - Fax:718-981-9344
Practice Address - Street 1:263 /267 PORT RICHMOND AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302
Practice Address - Country:US
Practice Address - Phone:718-981-8117
Practice Address - Fax:718-981-9344
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY361237-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse