Provider Demographics
NPI:1669984464
Name:ROGALA, REGINA VALORIE
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:VALORIE
Last Name:ROGALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BUCHHOLTZ RD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN CITY
Mailing Address - State:WI
Mailing Address - Zip Code:54629
Mailing Address - Country:US
Mailing Address - Phone:205-303-0033
Mailing Address - Fax:
Practice Address - Street 1:321 WAGON DR APT 202
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-1009
Practice Address - Country:US
Practice Address - Phone:608-451-5965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI96378163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory