Provider Demographics
NPI:1083133169
Name:ROGERS, STACIE LIN (LPN)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LIN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12283 STATE ROUTE 193
Mailing Address - Street 2:
Mailing Address - City:ELLISBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13636-2115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12283 STATE ROUTE 193
Practice Address - Street 2:
Practice Address - City:ELLISBURG
Practice Address - State:NY
Practice Address - Zip Code:13636
Practice Address - Country:US
Practice Address - Phone:315-783-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326563164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse