Healthcare Provider Details

I. General information

NPI: 1578042701
Provider Name (Legal Business Name): KALLYN ROGERS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22331 MISSION BLVD
HAYWARD CA
94541
US

IV. Provider business mailing address

22331 MISSION BLVD
HAYWARD CA
94541-3911
US

V. Phone/Fax

Practice location:
  • Phone: 510-471-5907
  • Fax:
Mailing address:
  • Phone: 510-471-5580
  • Fax: 510-690-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95008273
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: