Healthcare Provider Details

I. General information

NPI: 1770162703
Provider Name (Legal Business Name): ALEXIS NICOLE ROACH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS WAY # 664
LITTLE ROCK AR
72202-3500
US

IV. Provider business mailing address

PO BOX 959794
SAINT LOUIS MO
63195-9794
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-2505
  • Fax: 501-978-6436
Mailing address:
  • Phone: 501-364-1100
  • Fax: 501-978-6436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-18038
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberE-18038
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: