Provider Demographics
NPI:1023592300
Name:ROGERS, DANIELLE LEE (NP)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LEE
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 1:550 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2920 S MCINTIRE DR STE 350
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4215
Practice Address - Country:US
Practice Address - Phone:812-332-2226
Practice Address - Fax:812-339-2934
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008374A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP02151167OtherRAILROAD PTAN
IN300019229Medicaid
IN090540381OtherMEDICARE PTAN