Provider Demographics
NPI:1255572889
Name:ROACH, ELAINE (LD/N MPH)
Entity type:Individual
Prefix:MISS
First Name:ELAINE
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:LD/N MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 170084
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33017-0084
Mailing Address - Country:US
Mailing Address - Phone:954-367-6192
Mailing Address - Fax:305-816-5844
Practice Address - Street 1:9680 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6246
Practice Address - Country:US
Practice Address - Phone:954-367-6192
Practice Address - Fax:954-342-9624
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133VN1101XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, GerontologicalGroup - Single Specialty