Healthcare Provider Details

I. General information

NPI: 1407355217
Provider Name (Legal Business Name): SHIRLEY GWEN ROGERSON MPH,BSN,RN,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 S FLORIDA AVE
LAKELAND FL
33813-2165
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-284-3950
  • Fax: 863-284-3951
Mailing address:
  • Phone: 863-284-1604
  • Fax: 863-687-1412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN9170975
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number917905
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number9170975
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: