Healthcare Provider Details

I. General information

NPI: 1922058726
Provider Name (Legal Business Name): BETH ROGERS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR
MANTENO IL
60950-9466
US

IV. Provider business mailing address

701 S CHESTNUT ST
WENONA IL
61377
US

V. Phone/Fax

Practice location:
  • Phone: 815-468-1027
  • Fax:
Mailing address:
  • Phone: 815-853-4688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: