Healthcare Provider Details

I. General information

NPI: 1962388330
Provider Name (Legal Business Name): DIANE JOYCE ROARK ACAG-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S BROADWAY AVE
SALEM OH
44460-3002
US

IV. Provider business mailing address

6859 FAIRGROUND BLVD
CANFIELD OH
44406-1550
US

V. Phone/Fax

Practice location:
  • Phone: 220-270-6900
  • Fax:
Mailing address:
  • Phone: 916-365-3590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN420692
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.0039994
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: