Provider Demographics
NPI:1467274472
Name:ROACH, MARY CHARLENE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CHARLENE
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:PO BOX 90
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WV
Mailing Address - Zip Code:25247-0090
Mailing Address - Country:US
Mailing Address - Phone:304-812-7455
Mailing Address - Fax:
Practice Address - Street 1:218 FRUTH LN
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:WV
Practice Address - Zip Code:25260-1280
Practice Address - Country:US
Practice Address - Phone:304-675-0567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty