Healthcare Provider Details

I. General information

NPI: 1770052185
Provider Name (Legal Business Name): TIMOTHY MITCHEL ROARK MSN, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 DRY RIDGE RD
CINCINNATI OH
45252-3014
US

IV. Provider business mailing address

3636 VERNIER DR
CINCINNATI OH
45251-2432
US

V. Phone/Fax

Practice location:
  • Phone: 513-981-5162
  • Fax:
Mailing address:
  • Phone: 513-512-8510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.026312
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: