Provider Demographics
NPI:1093317513
Name:ROGERS, ANDREA D
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:D
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 1:7717 W GOOD HOPE RD APT 108
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-4505
Mailing Address - Country:US
Mailing Address - Phone:252-357-1422
Mailing Address - Fax:
Practice Address - Street 1:7717 W GOOD HOPE RD APT 108
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-4505
Practice Address - Country:US
Practice Address - Phone:252-357-1422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100133091Medicaid