Healthcare Provider Details

I. General information

NPI: 1235722646
Provider Name (Legal Business Name): GLADYS E ROGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5237 KENILWORTH AVE # 2
HYATTSVILLE MD
20781-2857
US

IV. Provider business mailing address

5237 KENILWORTH AVE
HYATTSVILLE MD
20781-2857
US

V. Phone/Fax

Practice location:
  • Phone: 240-413-4055
  • Fax: 410-946-2010
Mailing address:
  • Phone: 240-413-4055
  • Fax: 410-946-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP55347
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: