Provider Demographics
NPI:1750598835
Name:ROARK, BERTHA ANN (RN)
Entity type:Individual
Prefix:MRS
First Name:BERTHA
Middle Name:ANN
Last Name:ROARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 N 3RD ST.
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413
Mailing Address - Country:US
Mailing Address - Phone:505-634-3673
Mailing Address - Fax:505-634-3675
Practice Address - Street 1:310 LA JARA ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-6626
Practice Address - Country:US
Practice Address - Phone:505-634-3673
Practice Address - Fax:505-634-3675
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR18502163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64434826Medicaid