Provider Demographics
NPI:1497357743
Name:ROGERS, AMANDA (PHD APRN MHS CPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PHD APRN MHS CPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD APRN MHS CPT
Mailing Address - Street 1:505 N MAIN ST # 1113
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-9994
Mailing Address - Country:US
Mailing Address - Phone:203-510-1234
Mailing Address - Fax:
Practice Address - Street 1:505 N MAIN ST # 1113
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-9994
Practice Address - Country:US
Practice Address - Phone:203-510-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT20-1508Y10246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT157404580OtherDRIVERS LICENSE