Healthcare Provider Details

I. General information

NPI: 1457100869
Provider Name (Legal Business Name): MICHELLE L ROGERS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2024
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5110 FAIRFIELD RD
COLUMBIA SC
29203-4323
US

IV. Provider business mailing address

PO BOX 740013
ATLANTA GA
30374-0013
US

V. Phone/Fax

Practice location:
  • Phone: 803-893-7019
  • Fax:
Mailing address:
  • Phone: 312-733-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28211
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number28211
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: