Provider Demographics
NPI:1588235501
Name:ROARK, SUSAN KAY
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:ROARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 MANOWAR BLVD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515
Mailing Address - Country:US
Mailing Address - Phone:859-273-0088
Mailing Address - Fax:859-273-0089
Practice Address - Street 1:2710 MANOWAR BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515
Practice Address - Country:US
Practice Address - Phone:859-273-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1052883163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse