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General NPI Number Information
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NPI Number | 1255996732
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Entity Type | Individual
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Provider Name | KELLY ROARK FNP
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Gender | Female
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Dates
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Enumeration Date | 05/09/2019
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Last Update Date | 05/09/2019
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Provider Practice Location Address
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Address Line | 20 ALPINE DR
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City | BATESVILLE
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State | IN
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Zip | 47006-8477
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Country | US
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Telephone | 812-932-3224
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Fax |
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Provider Business Mailing Address
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Address Line | 15923 STATE ROAD 156
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City | PATRIOT
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State | IN
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Zip | 47038-9210
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Country | US
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Telephone | 812-290-7637
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APRN.CNP.024625
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 28154325A
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License Number State | IN
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