Healthcare Provider Details

I. General information

NPI: 1104886233
Provider Name (Legal Business Name): ELIZABETH ROACH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 BRENNER AVE
SALISBURY NC
28144-2515
US

IV. Provider business mailing address

1102 WEAVER RD
LEXINGTON NC
27295-5413
US

V. Phone/Fax

Practice location:
  • Phone: 704-638-9000
  • Fax: 704-638-3434
Mailing address:
  • Phone: 336-731-6515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number134355
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: