Provider Demographics
NPI:1174722029
Name:ROARK, SHANNON MARIE (MS, RDN, CLC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:ROARK
Suffix:
Gender:F
Credentials:MS, RDN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 TREASURE LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7816
Mailing Address - Country:US
Mailing Address - Phone:423-202-6404
Mailing Address - Fax:423-979-3261
Practice Address - Street 1:185 TREASURE LN
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7816
Practice Address - Country:US
Practice Address - Phone:423-202-6404
Practice Address - Fax:423-979-3261
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN917714133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid
TNPENDINGMedicare PIN
TNPENDINGMedicare UPIN
TN02817/0001Medicare PIN
TNPENDINGMedicaid