Provider Demographics
NPI:1164863262
Name:ROARK, MICHELLE L (CNM)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:ROARK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5208
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5208
Mailing Address - Country:US
Mailing Address - Phone:601-486-4210
Mailing Address - Fax:601-486-4219
Practice Address - Street 1:905C S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-6113
Practice Address - Country:US
Practice Address - Phone:601-486-4210
Practice Address - Fax:601-482-4219
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA810516176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08106745Medicaid