Provider Demographics
NPI:1902192776
Name:ROGERS, KIMBERLY (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
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 1:940 PARK EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905
Mailing Address - Country:US
Mailing Address - Phone:765-464-2280
Mailing Address - Fax:
Practice Address - Street 1:940 PARK EAST BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905
Practice Address - Country:US
Practice Address - Phone:765-464-2280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28150957A163W00000X
IN71003703A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201034790Medicaid
IN000000731417OtherANTHEM PROVIDER NUMBER
IN201034790Medicaid
IN000000731417OtherANTHEM PROVIDER NUMBER