Healthcare Provider Details

I. General information

NPI: 1710508296
Provider Name (Legal Business Name): DECOLIA RONIC ROGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 COOLIDGE BLVD
LAFAYETTE LA
70503-2621
US

IV. Provider business mailing address

926 FRISKY DR
BRANDON MS
39047-7070
US

V. Phone/Fax

Practice location:
  • Phone: 337-289-7991
  • Fax:
Mailing address:
  • Phone: 601-575-4069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number211857
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number211857
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: