Provider Demographics
NPI:1538100342
Name:ROPER, SALLY K (ARNP,FNP)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:K
Last Name:ROPER
Suffix:
Gender:F
Credentials:ARNP,FNP
Other - Prefix:MISS
Other - First Name:SALLY
Other - Middle Name:K
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19 TIMBERLANE DR
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50428-1164
Mailing Address - Country:US
Mailing Address - Phone:641-421-8077
Mailing Address - Fax:515-699-5761
Practice Address - Street 1:910 N EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-1525
Practice Address - Country:US
Practice Address - Phone:641-421-8077
Practice Address - Fax:515-699-5761
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA091039163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS-60907Medicare UPIN