Provider Demographics
NPI:1295417699
Name:ROACH, AMANDA LEE (BSN, RN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:ROACH
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEE
Other - Last Name:BOWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:23 E ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-6423
Mailing Address - Country:US
Mailing Address - Phone:918-227-2016
Mailing Address - Fax:
Practice Address - Street 1:23 E ROSS AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-6423
Practice Address - Country:US
Practice Address - Phone:918-227-2016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0077682163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health