MEDICARE: CRYSTAL GAIL ROGERS FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	206388	TN
2	363LA2100X	Acute Care Nurse Practitioner	206388	TN
3	207Q00000X	Family Medicine Physician	24364	TN

General Provider Information

NPI Number	:	1427549377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL GAIL ROGERS FNP-C

Provider Business Mailing Address
First Line	:	1338 RUSSELL AVE
Second Line	:
City	:	JEFFERSON CITY
State	:	TN
Zip	:	37760-2761
Country	:	US
Telephone Number	:	865-262-0049
Fax Number	:	865-262-0106

Provider Business Practice Location Address
First Line	:	1338 RUSSELL AVE
Second Line	:
City	:	JEFFERSON CITY
State	:	TN
Zip	:	37760-2761
Country	:	US
Telephone Number	:	865-262-0049
Fax Number	:	865-262-0106

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2018
Last Update Date	:	12/11/2024

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