Provider Demographics
NPI:1932785243
Name:ROGERS, KRISTYN MAE
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:MAE
Last Name:ROGERS
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 1:1330 E 8TH ST STE 206
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4731
Mailing Address - Country:US
Mailing Address - Phone:432-550-1721
Mailing Address - Fax:
Practice Address - Street 1:1330 E 8TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4702
Practice Address - Country:US
Practice Address - Phone:432-550-1721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2147150225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant