Healthcare Provider Details

I. General information

NPI: 1083170559
Provider Name (Legal Business Name): SHELLY GUNNELL ROARK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 02/24/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5003 HARDY ST STE 350
HATTIESBURG MS
39402-1323
US

IV. Provider business mailing address

6524 U S HIGHWAY 98
HATTIESBURG MS
39402-8569
US

V. Phone/Fax

Practice location:
  • Phone: 601-268-9393
  • Fax: 601-268-9559
Mailing address:
  • Phone: 601-268-9393
  • Fax: 601-268-9559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number902947
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number902947
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: