Provider Demographics
NPI:1134544356
Name:ROACH, MACY (NP)
Entity type:Individual
Prefix:MRS
First Name:MACY
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9505 14TH BAY ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-6208
Mailing Address - Country:US
Mailing Address - Phone:757-965-9406
Mailing Address - Fax:
Practice Address - Street 1:2315 W MERCURY BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3114
Practice Address - Country:US
Practice Address - Phone:757-262-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171227363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily