=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295975332
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN ELIZEBETH ROGGE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2009
-----------------------------------------------------
Last Update Date | 03/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 94146 CHILCOOT AVE.
-----------------------------------------------------
City | CHILCOOT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-993-4339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 73
-----------------------------------------------------
City | CHILCOOT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96105-0073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-993-4339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 11160LPN
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------