Provider Demographics
NPI:1881171247
Name:ROGERS, KRYSTAL RENEE' (RN)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:RENEE'
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 1:2100 BULL STREET
Mailing Address - Street 2:N-123
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201
Mailing Address - Country:US
Mailing Address - Phone:803-898-1922
Mailing Address - Fax:803-898-0163
Practice Address - Street 1:2100 BULL STREET
Practice Address - Street 2:N-123
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-898-1922
Practice Address - Fax:803-898-0163
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC219482163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse