Provider Demographics
NPI:1063613081
Name:ROGERS, BRENDA ANN (APRN)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:ANN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1495
Mailing Address - Country:US
Mailing Address - Phone:617-591-6300
Mailing Address - Fax:
Practice Address - Street 1:236 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1495
Practice Address - Country:US
Practice Address - Phone:617-298-4400
Practice Address - Fax:617-298-2100
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA126513363LP0808X
MARN126513363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0211978Medicaid
MAS47430Medicare UPIN
MANP086303Medicare PIN