MEDICARE: SHANNON MARIE ROARK MS, RDN, CLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	917714	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174722029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON MARIE ROARK MS, RDN, CLC

Provider Business Mailing Address
First Line	:	185 TREASURE LN
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-7816
Country	:	US
Telephone Number	:	423-202-6404
Fax Number	:	423-979-3261

Provider Business Practice Location Address
First Line	:	185 TREASURE LN
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-7816
Country	:	US
Telephone Number	:	423-202-6404
Fax Number	:	423-979-3261

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2007
Last Update Date	:	03/24/2025

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