Healthcare Provider Details

I. General information

NPI: 1114323573
Provider Name (Legal Business Name): KRISTIN LAINE ROGERS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 WHITCHER ST NE STE 4120
MARIETTA GA
30060-1179
US

IV. Provider business mailing address

1557 JANMAR RD
SNELLVILLE GA
30078-5686
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-9732
  • Fax:
Mailing address:
  • Phone: 678-344-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7420
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: