Provider Demographics
NPI:1053668236
Name:ROGERS, ANTIONETTE DARNELL
Entity Type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:DARNELL
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4365 NORTHFIELD RD APT 205A
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-4643
Mailing Address - Country:US
Mailing Address - Phone:216-682-5644
Mailing Address - Fax:
Practice Address - Street 1:4365 NORTHFIELD RD APT 205A
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-4643
Practice Address - Country:US
Practice Address - Phone:216-682-5644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401229320411376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide