Provider Demographics
NPI:1275839342
Name:ROGERS, LISA JAN (LPN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JAN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JAN
Other - Last Name:COSTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:10566 COUNTY HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:SOUTH KORTRIGHT
Mailing Address - State:NY
Mailing Address - Zip Code:13842-2451
Mailing Address - Country:US
Mailing Address - Phone:607-538-1417
Mailing Address - Fax:
Practice Address - Street 1:10566 COUNTY HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:SOUTH KORTRIGHT
Practice Address - State:NY
Practice Address - Zip Code:13842-2451
Practice Address - Country:US
Practice Address - Phone:607-538-1417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY283335-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse