Provider Demographics
NPI:1568822989
Name:BAMFORD, ROANNA LEIGH (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ROANNA
Middle Name:LEIGH
Last Name:BAMFORD
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 HUNTINGTON AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5902
Mailing Address - Country:US
Mailing Address - Phone:617-879-5220
Mailing Address - Fax:
Practice Address - Street 1:2225 PORTLAND ST
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819
Practice Address - Country:US
Practice Address - Phone:802-748-3181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN230901363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health