Provider Demographics
NPI:1902343957
Name:ROARK, SUSETTE R (APRN)
Entity Type:Individual
Prefix:
First Name:SUSETTE
Middle Name:R
Last Name:ROARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5200 COMMERCE CROSSINGS DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:3900 KRESGE WAY
Practice Address - Street 2:STE 46
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4660
Practice Address - Country:US
Practice Address - Phone:502-899-3858
Practice Address - Fax:502-899-3878
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71006841A363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71006841BOtherCDS LICENSE