Provider Demographics
NPI:1699771311
Name:ROARK, AMY N (LD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:N
Last Name:ROARK
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 JESSE JEWELL PKWY SE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3862
Mailing Address - Country:US
Mailing Address - Phone:770-536-9864
Mailing Address - Fax:770-297-5023
Practice Address - Street 1:1240 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE 500
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3862
Practice Address - Country:US
Practice Address - Phone:770-536-9864
Practice Address - Fax:770-297-5023
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
71BBBHFMedicare ID - Type Unspecified