Provider Demographics
NPI:1851543789
Name:ROACH, IDA LEE (LPN)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:LEE
Last Name:ROACH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 N 48TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-3432
Mailing Address - Country:US
Mailing Address - Phone:414-915-4926
Mailing Address - Fax:
Practice Address - Street 1:5319 N 48TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-3432
Practice Address - Country:US
Practice Address - Phone:414-915-4926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI309438-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse