Healthcare Provider Details

I. General information

NPI: 1740388271
Provider Name (Legal Business Name): PHYLLIS R ROGERS RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4459 TIMBERWOOD DR
GASTONIA NC
28056-8427
US

IV. Provider business mailing address

4459 TIMBERWOOD DR
GASTONIA NC
28056-8427
US

V. Phone/Fax

Practice location:
  • Phone: 704-674-3204
  • Fax:
Mailing address:
  • Phone: 704-674-3204
  • Fax: 704-853-5188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number192329
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: