Provider Demographics
NPI:1225174055
Name:ROGERS, DENINE MARION (RD LD)
Entity Type:Individual
Prefix:MS
First Name:DENINE
Middle Name:MARION
Last Name:ROGERS
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:MS
Other - First Name:DENINE
Other - Middle Name:MARION
Other - Last Name:YOUNG - ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:1075 WALKER PLACE DRIVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134
Mailing Address - Country:US
Mailing Address - Phone:678-952-9881
Mailing Address - Fax:770-693-1185
Practice Address - Street 1:1075 WALKER PLACE DRIVE
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134
Practice Address - Country:US
Practice Address - Phone:678-952-9881
Practice Address - Fax:770-693-1185
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001969133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBSJMedicaid
GA71BBBHRMedicare UPIN
GA844240284AMedicare ID - Type Unspecified