Provider Demographics
NPI:1386112183
Name:ROGERS, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
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 1:14416 119TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11436-1512
Mailing Address - Country:US
Mailing Address - Phone:917-400-8558
Mailing Address - Fax:
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5317
Practice Address - Country:US
Practice Address - Phone:718-963-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY826298133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered