Healthcare Provider Details

I. General information

NPI: 1629117197
Provider Name (Legal Business Name): SUSAN M ROCHE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W 12TH ST
ERIE PA
16505-4508
US

IV. Provider business mailing address

2500 W 12TH ST
ERIE PA
16505-4508
US

V. Phone/Fax

Practice location:
  • Phone: 814-838-9000
  • Fax:
Mailing address:
  • Phone: 814-838-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberVP003651C
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN224580L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: