Healthcare Provider Details

I. General information

NPI: 1518461540
Provider Name (Legal Business Name): CHRISANNE GENNILLE ROACH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 AVENT FERRY RD STE 106
HOLLY SPRINGS NC
27540-7776
US

IV. Provider business mailing address

1874 BLUE JAY PT
APEX NC
27502-9711
US

V. Phone/Fax

Practice location:
  • Phone: 919-567-6133
  • Fax: 919-567-6134
Mailing address:
  • Phone: 786-202-1796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2022-00998
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: