Provider Demographics
NPI:1154772200
Name:ROACH, COLLEEN (CRNP-F)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:CRNP-F
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6901 SECURITY BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2412
Mailing Address - Country:US
Mailing Address - Phone:410-837-2050
Mailing Address - Fax:410-752-1374
Practice Address - Street 1:6901 SECURITY BLVD STE 200
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-2412
Practice Address - Country:US
Practice Address - Phone:410-837-2050
Practice Address - Fax:410-752-1374
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR046352363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily