Provider Demographics
NPI:1790817484
Name:ROGERS, MARY ELLEN B (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:B
Last Name:ROGERS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6350 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-1430
Mailing Address - Country:US
Mailing Address - Phone:813-977-0733
Mailing Address - Fax:813-971-2230
Practice Address - Street 1:6350 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1430
Practice Address - Country:US
Practice Address - Phone:813-977-0733
Practice Address - Fax:813-971-2230
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 3147572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP 3147572OtherNURSE PRACTITIONER