Provider Demographics
NPI:1902846876
Name:ROACH, DIANE (CNM)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 WESLEY AVENUE
Mailing Address - Street 2:STE. N
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2274
Mailing Address - Country:US
Mailing Address - Phone:513-569-6422
Mailing Address - Fax:513-569-5084
Practice Address - Street 1:3440 BURNETT AVE.
Practice Address - Street 2:STE. 120
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-2833
Practice Address - Country:US
Practice Address - Phone:513-751-5900
Practice Address - Fax:513-487-4596
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNM02342367A00000X
OHRN209167367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0801850Medicaid
KY78009529Medicaid
OHRONM02777Medicare PIN
OHRONM02773Medicare PIN
KY78009529Medicaid
OH0801850Medicaid