MEDICARE: ABIGAIL JOANN GLENZEL ROACH CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	SP015379	PA
2	363LA2200X	Adult Health Nurse Practitioner	SP015379	PA

General Provider Information

NPI Number	:	1265888549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIGAIL JOANN GLENZEL ROACH CRNP

Provider Business Mailing Address
First Line	:	3400 SPRUCE STREET
Second Line	:	GROUND FLOOR RAVDIN
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104
Country	:	US
Telephone Number	:	215-600-5535
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 SPRUCE STREET
Second Line	:	GROUND FLOOR RAVDIN
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104
Country	:	US
Telephone Number	:	215-600-5535
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2016
Last Update Date	:	07/21/2022

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