Provider Demographics
NPI:1013599224
Name:ROACH, TALIA LYNTASHA
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:LYNTASHA
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6752
Mailing Address - Country:US
Mailing Address - Phone:336-542-8732
Mailing Address - Fax:
Practice Address - Street 1:1302 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6752
Practice Address - Country:US
Practice Address - Phone:336-542-8732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist