Provider Demographics
NPI:1255996732
Name:ROARK, KELLY (FNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ROARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15923 STATE ROAD 156
Mailing Address - Street 2:
Mailing Address - City:PATRIOT
Mailing Address - State:IN
Mailing Address - Zip Code:47038-9210
Mailing Address - Country:US
Mailing Address - Phone:812-290-7637
Mailing Address - Fax:
Practice Address - Street 1:20 ALPINE DR
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47006-8477
Practice Address - Country:US
Practice Address - Phone:812-932-3224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024625363LF0000X
IN28154325A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily