Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | A810516 | MS |
NPI | 1164863262 |
---|---|
Provider Name | Michelle L Roark |
First Address | Meridian, MS 39302-5208 |
Second Address | Meridian, MS 39301-6113 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2013 |
Last Update Date | 18/02/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
08106745 | (05) | MS |