Healthcare Provider Details

I. General information

NPI: 1417578675
Provider Name (Legal Business Name): MICHELLE PATRICIA ROGGERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 RANGOON PL
DULLES VA
20189-4249
US

IV. Provider business mailing address

UNIT 4250 BOX 108
DPO AE
09976-0108
US

V. Phone/Fax

Practice location:
  • Phone: 944-527-0496
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024177953
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: