Provider Demographics
NPI:1134332117
Name:ROARK, WANDA KAY (RN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:KAY
Last Name:ROARK
Suffix:
Gender:F
Credentials:RN, FNP-BC
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:KAY
Other - Last Name:MEADOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, FNP
Mailing Address - Street 1:1604 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801-5314
Mailing Address - Country:US
Mailing Address - Phone:325-646-5296
Mailing Address - Fax:325-646-5820
Practice Address - Street 1:307 LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:MARLIN
Practice Address - State:TX
Practice Address - Zip Code:76661-2365
Practice Address - Country:US
Practice Address - Phone:254-803-3561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX675522363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX288263Medicare PIN