Healthcare Provider Details

I. General information

NPI: 1639389042
Provider Name (Legal Business Name): ILEANA ROGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ILEANA ROGERS RN

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 HARDEE AVENUE S. W.
FORT MCPHERSON GA
30330
US

IV. Provider business mailing address

9892 POINT VIEW DR
JONESBORO GA
30238-7858
US

V. Phone/Fax

Practice location:
  • Phone: 404-464-0327
  • Fax: 404-464-0415
Mailing address:
  • Phone: 770-471-8912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR119677
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: