Provider Demographics
NPI:1265608194
Name:RODGERS, TANYA L (LPN)
Entity type:Individual
Prefix:MS
First Name:TANYA
Middle Name:L
Last Name:RODGERS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4252 N 74TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1051
Mailing Address - Country:US
Mailing Address - Phone:414-352-8563
Mailing Address - Fax:414-352-8593
Practice Address - Street 1:4252 N 74TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1051
Practice Address - Country:US
Practice Address - Phone:414-352-8563
Practice Address - Fax:414-352-8593
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI303821-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35018100Medicare PIN