Provider Demographics
NPI:1326537846
Name:ROARK, JUSTIN LANE (RN)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:LANE
Last Name:ROARK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 TRANSUE DR
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7358
Mailing Address - Country:US
Mailing Address - Phone:501-612-0065
Mailing Address - Fax:
Practice Address - Street 1:4141 TRANSUE DRIVE
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542
Practice Address - Country:US
Practice Address - Phone:501-612-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9420912163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse