Provider Demographics
NPI:1417555897
Name:ROGERS, CARLA R (NP-C)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:R
Last Name:ROGERS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 CROSSROADS PL STE 100
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6545
Mailing Address - Country:US
Mailing Address - Phone:618-241-9071
Mailing Address - Fax:
Practice Address - Street 1:209 CROSSROADS PL STE 100
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6545
Practice Address - Country:US
Practice Address - Phone:618-241-9071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.021015363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner