Provider Demographics
NPI:1639873235
Name:ROARK, STEPHANIE SHADDEN (RD)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:SHADDEN
Last Name:ROARK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 SHADDEN RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4240
Mailing Address - Country:US
Mailing Address - Phone:423-791-1263
Mailing Address - Fax:
Practice Address - Street 1:325 N STATE OF FRANKLIN RD FL 1
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6056
Practice Address - Country:US
Practice Address - Phone:423-439-7272
Practice Address - Fax:423-439-7235
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4588133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ24385AMedicaid