Provider Demographics
NPI:1912688045
Name:ROGERS, THEA (DNP, APRN, CPNP, RN)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:DNP, APRN, CPNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 N WILDER BLVD
Mailing Address - Street 2:
Mailing Address - City:HERMOSA
Mailing Address - State:SD
Mailing Address - Zip Code:57744-5424
Mailing Address - Country:US
Mailing Address - Phone:612-910-0278
Mailing Address - Fax:
Practice Address - Street 1:155 N WILDER BLVD
Practice Address - Street 2:
Practice Address - City:HERMOSA
Practice Address - State:SD
Practice Address - Zip Code:57744-5424
Practice Address - Country:US
Practice Address - Phone:612-910-0278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR050996163WN0002X
MN2465896163WN0002X
SDCP002999363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care