Provider Demographics
NPI:1548896301
Name:CORK, ROCHELLE VANITY (NP)
Entity type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:VANITY
Last Name:CORK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:ROCHELLE
Other - Middle Name:
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:4635 US-80
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208
Mailing Address - Country:US
Mailing Address - Phone:601-933-2500
Mailing Address - Fax:
Practice Address - Street 1:4635 US-80
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208
Practice Address - Country:US
Practice Address - Phone:601-933-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903496363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology