Provider Demographics
NPI:1285108548
Name:BOGALIS, ROXANNE DONNA-SHEA
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:DONNA-SHEA
Last Name:BOGALIS
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 1:14530 CALLEN GLEN WAY
Mailing Address - Street 2:
Mailing Address - City:WIMAUMA
Mailing Address - State:FL
Mailing Address - Zip Code:33598-6180
Mailing Address - Country:US
Mailing Address - Phone:941-769-1650
Mailing Address - Fax:
Practice Address - Street 1:14530 CALLEN GLEN WAY
Practice Address - Street 2:
Practice Address - City:WIMAUMA
Practice Address - State:FL
Practice Address - Zip Code:33598-6180
Practice Address - Country:US
Practice Address - Phone:941-769-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 174H00000X, 174N00000X, 374J00000X
FLP5251927164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula