Provider Demographics
NPI:1629091194
Name:ROGERS, MARY S (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:ROGERS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 BREMO RD
Mailing Address - Street 2:STE 506
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1925
Mailing Address - Country:US
Mailing Address - Phone:804-287-7840
Mailing Address - Fax:804-287-7845
Practice Address - Street 1:5875 BREMO RD
Practice Address - Street 2:SUITE G-5
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1934
Practice Address - Country:US
Practice Address - Phone:804-287-7840
Practice Address - Fax:804-287-7845
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024105235363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0017000649OtherNP PRESCRIPTIVE AUTHORITY
VA0001105235OtherRN LICENSE
VA0024105235OtherNURSE PRACTITIONER LICENS
VA0024105235OtherNURSE PRACTITIONER LICENS
VA0017000649OtherNP PRESCRIPTIVE AUTHORITY
VA004796C18Medicare ID - Type Unspecified