Provider Demographics
NPI:1730218561
Name:BROOKS-ROACH, WANTINA WYNETTE (LCPM)
Entity type:Individual
Prefix:MRS
First Name:WANTINA
Middle Name:WYNETTE
Last Name:BROOKS-ROACH
Suffix:
Gender:F
Credentials:LCPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 N LOOP 1604 E # 105187
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1339
Mailing Address - Country:US
Mailing Address - Phone:805-738-8824
Mailing Address - Fax:866-399-0991
Practice Address - Street 1:10 GIRARD ST STE B
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-5106
Practice Address - Country:US
Practice Address - Phone:859-363-6050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9000017176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9000017OtherKENTUCKY MIDWIFE LICENSE