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General NPI Number Information
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NPI Number | 1083170559
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Entity Type | Individual
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Provider Name | SHELLY GUNNELL ROARK NURSE PRACTITIONER
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Gender | Female
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Dates
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Enumeration Date | 02/20/2019
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Last Update Date | 02/24/2025
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Provider Practice Location Address
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Address Line | 5003 HARDY ST STE 350
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City | HATTIESBURG
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State | MS
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Zip | 39402-1323
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Country | US
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Telephone | 601-268-9393
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Fax | 601-268-9559
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Provider Business Mailing Address
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Address Line | 6524 U S HIGHWAY 98
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City | HATTIESBURG
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State | MS
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Zip | 39402-8569
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Country | US
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Telephone | 601-268-9393
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Fax | 601-268-9559
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LC1500X
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Taxonomy Name | Community Health Nurse Practitioner
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License Number | 902947
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | 902947
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License Number State | MS
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