Healthcare Provider Details

I. General information

NPI: 1053649913
Provider Name (Legal Business Name): MARIANA OLGA ROCHE CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2009
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PLZ
DAYTON OH
45404-1873
US

IV. Provider business mailing address

462 CHRISTOPHER DR
CENTERVILLE OH
45458-4976
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-3111
  • Fax:
Mailing address:
  • Phone: 937-885-1584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number11207-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: