Provider Demographics
NPI:1770162703
Name:ROACH, ALEXIS NICOLE (DO)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:NICOLE
Last Name:ROACH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 959794
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-9794
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:501-978-6436
Practice Address - Street 1:1 CHILDRENS WAY # 664
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-2505
Practice Address - Fax:501-978-6436
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE-18038208000000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics