Provider Demographics
NPI:1184240285
Name:ROACH, MIRANDA MICHELLE (FNP-C)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MICHELLE
Last Name:ROACH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11907 CANDLEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-5427
Mailing Address - Country:US
Mailing Address - Phone:720-480-3790
Mailing Address - Fax:
Practice Address - Street 1:11907 CANDLEWOOD PL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-5427
Practice Address - Country:US
Practice Address - Phone:720-480-3790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily