Healthcare Provider Details

I. General information

NPI: 1386201374
Provider Name (Legal Business Name): JENNIFER HOPE ROARK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 RUIN CREEK RD., PO DRAWER 59
HENDERSON NC
27536-2927
US

IV. Provider business mailing address

PO BOX 2295
ASHEVILLE NC
28802-2295
US

V. Phone/Fax

Practice location:
  • Phone: 252-438-4143
  • Fax:
Mailing address:
  • Phone: 828-398-5244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number256295
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: