Healthcare Provider Details

I. General information

NPI: 1023824075
Provider Name (Legal Business Name): STACI ROARK BSN, RN, CA/CP SANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 INDIANA AVE
LUBBOCK TX
79415-3364
US

IV. Provider business mailing address

602 INDIANA AVE
LUBBOCK TX
79415-3364
US

V. Phone/Fax

Practice location:
  • Phone: 806-775-9700
  • Fax:
Mailing address:
  • Phone: 806-775-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1087531
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: