Provider Demographics
NPI:1144961053
Name:RODGERS, MARK EDWARD (RN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:RODGERS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35022 PERSIMMON AVE
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-3116
Mailing Address - Country:US
Mailing Address - Phone:909-226-5081
Mailing Address - Fax:
Practice Address - Street 1:35022 PERSIMMON AVE
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-3116
Practice Address - Country:US
Practice Address - Phone:909-226-5081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA402565163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management