Provider Demographics
NPI:1033079223
Name:ROACH, VERNA JEWEL
Entity type:Individual
Prefix:
First Name:VERNA
Middle Name:JEWEL
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 CROMWELL RD
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1657
Mailing Address - Country:US
Mailing Address - Phone:636-208-6474
Mailing Address - Fax:
Practice Address - Street 1:503 CROMWELL RD
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1657
Practice Address - Country:US
Practice Address - Phone:636-208-6474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-12
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOL127081001347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle