Provider Demographics
NPI:1417578675
Name:ROGGERO, MICHELLE PATRICIA
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:PATRICIA
Last Name:ROGGERO
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:UNIT 4250 BOX 108
Mailing Address - Street 2:
Mailing Address - City:DPO
Mailing Address - State:AE
Mailing Address - Zip Code:09976-0108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4250 RANGOON PL
Practice Address - Street 2:
Practice Address - City:DULLES
Practice Address - State:VA
Practice Address - Zip Code:20189-4249
Practice Address - Country:US
Practice Address - Phone:944-527-0496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177953363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily