Provider Demographics
NPI:1396115465
Name:ROGERS, CRYSTAL L (ANP/GNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:ROGERS
Suffix:
Gender:F
Credentials:ANP/GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8268 164TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1121
Mailing Address - Country:US
Mailing Address - Phone:718-883-3000
Mailing Address - Fax:718-883-6295
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:718-883-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307517363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health