Healthcare Provider Details

I. General information

NPI: 1952148629
Provider Name (Legal Business Name): KELLIE LYNN ROGERO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 ROSS CLARK CIR
DOTHAN AL
36301-3022
US

IV. Provider business mailing address

1108 ROSS CLARK CIR
DOTHAN AL
36301-3022
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-8111
  • Fax:
Mailing address:
  • Phone: 334-618-4024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-092914
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: