Provider Demographics
NPI:1407305782
Name:ROGERS, EARNESTINE
Entity Type:Individual
Prefix:
First Name:EARNESTINE
Middle Name:
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 1:4127 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-6148
Mailing Address - Country:US
Mailing Address - Phone:229-646-2217
Mailing Address - Fax:
Practice Address - Street 1:4127 PLAZA DR
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-6148
Practice Address - Country:US
Practice Address - Phone:229-646-2217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor