Provider Demographics
NPI:1083170559
Name:ROARK, SHELLY GUNNELL (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:GUNNELL
Last Name:ROARK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4312
Mailing Address - Country:US
Mailing Address - Phone:601-425-3033
Mailing Address - Fax:601-422-0431
Practice Address - Street 1:103 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4322
Practice Address - Country:US
Practice Address - Phone:601-399-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902947363LC1500X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPENDINGMedicaid