Provider Demographics
NPI:1851789598
Name:ROACH, THERESIA (NP-C)
Entity Type:Individual
Prefix:
First Name:THERESIA
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-5148
Mailing Address - Country:US
Mailing Address - Phone:731-926-4222
Mailing Address - Fax:731-926-4228
Practice Address - Street 1:3500 CLOVERDALE RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35633-1302
Practice Address - Country:US
Practice Address - Phone:256-284-7706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-092699363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1326373861OtherGROUP NPI
AL242535Medicaid