Provider Demographics
NPI:1578042701
Name:ROGERS, KALLYN (NP)
Entity Type:Individual
Prefix:
First Name:KALLYN
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22331 MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-3911
Mailing Address - Country:US
Mailing Address - Phone:510-471-5580
Mailing Address - Fax:510-690-0717
Practice Address - Street 1:22331 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541
Practice Address - Country:US
Practice Address - Phone:510-471-5907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008273363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics