Provider Demographics
NPI:1588331318
Name:ROGERS, SUSANNAH LEE (RN)
Entity type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:LEE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 515381
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-6681
Mailing Address - Country:US
Mailing Address - Phone:949-874-3391
Mailing Address - Fax:
Practice Address - Street 1:600 ENTERPRISE DR STE 220
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-4202
Practice Address - Country:US
Practice Address - Phone:844-632-7736
Practice Address - Fax:888-972-3621
Is Sole Proprietor?:No
Enumeration Date:2021-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041549618363LP0808X
CA95026173363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health