Provider Demographics
NPI:1962702621
Name:ROACH, CANDY E (FNP-BC)
Entity type:Individual
Prefix:
First Name:CANDY
Middle Name:E
Last Name:ROACH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:CANDY
Other - Middle Name:E
Other - Last Name:DOLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 BROOKS ST 200
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1848
Mailing Address - Country:US
Mailing Address - Phone:304-388-1930
Mailing Address - Fax:304-388-1929
Practice Address - Street 1:210 BROOKS ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1855
Practice Address - Country:US
Practice Address - Phone:304-388-1930
Practice Address - Fax:304-388-1929
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV58240363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NP39351Medicare PIN