=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821058462
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDY ROGNLI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2006
-----------------------------------------------------
Last Update Date | 06/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 963 ROBERT ST S
-----------------------------------------------------
City | WEST SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55118-1446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-726-9500
-----------------------------------------------------
Fax | 651-552-1575
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 963 ROBERT ST S
-----------------------------------------------------
City | WEST SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55118-1446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-726-9500
-----------------------------------------------------
Fax | 651-552-1575
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 534
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 092786-6
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------