Provider Demographics
NPI:1497106876
Name:ROARK, ASHLEY (NP)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:ROARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 LAPALCO BLVD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-4324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4225 LAPALCO BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-4324
Practice Address - Country:US
Practice Address - Phone:504-371-9355
Practice Address - Fax:504-371-9343
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09388574Medicaid
LA2426435Medicaid
MS09388574Medicaid