Healthcare Provider Details

I. General information

NPI: 1124378781
Provider Name (Legal Business Name): SUSAN RENE RODGERS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN RENE RODGERS ACNP-BC

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

V. Phone/Fax

Practice location:
  • Phone: 310-757-4597
  • Fax:
Mailing address:
  • Phone: 310-757-4597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5005993
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number5005993
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number213696
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: