Provider Demographics
NPI:1801076393
Name:ROGERS, GWENDOLYN (RN)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3127
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95353-3127
Mailing Address - Country:US
Mailing Address - Phone:209-558-8830
Mailing Address - Fax:209-558-8315
Practice Address - Street 1:830 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-558-8830
Practice Address - Fax:209-558-8315
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN445394171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator