Provider Demographics
NPI:1942864426
Name:ROGERS, KRYSTAL K (APRN)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:K
Last Name:ROGERS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:K
Other - Last Name:BANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:KRYSTAL HOUGHTELLING
Mailing Address - Street 1:PO DRAWER 367
Mailing Address - Street 2:
Mailing Address - City:LAPWAI
Mailing Address - State:ID
Mailing Address - Zip Code:83540-0367
Mailing Address - Country:US
Mailing Address - Phone:208-843-2271
Mailing Address - Fax:208-621-4995
Practice Address - Street 1:111 BEVER GRADE ROAD
Practice Address - Street 2:
Practice Address - City:LAPWAI
Practice Address - State:ID
Practice Address - Zip Code:83540-0367
Practice Address - Country:US
Practice Address - Phone:208-843-2271
Practice Address - Fax:208-621-4995
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60513914163W00000X
ID56934363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse