Provider Demographics
NPI:1891151403
Name:ROGERS, SHAWNTAY
Entity Type:Individual
Prefix:
First Name:SHAWNTAY
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHAWNTAY
Other - Middle Name:
Other - Last Name:GADSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CLC
Mailing Address - Street 1:3802 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6210
Mailing Address - Country:US
Mailing Address - Phone:912-663-8854
Mailing Address - Fax:912-354-1980
Practice Address - Street 1:3802 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6210
Practice Address - Country:US
Practice Address - Phone:912-663-8854
Practice Address - Fax:912-354-1980
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA238409174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN