Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LN0000X | Nurse Practitioner - Neonatal | 0024180335 | VA |
NPI | 1174087399 |
---|---|
Provider Name | Colleen Brynne Roach |
First Address | Norfolk, VA 23507-1971 |
Second Address | Norfolk, VA 23507-1910 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2019 |
Last Update Date | 14/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NONE | NONE (01) |