Provider Demographics
NPI:1699142935
Name:ROGERS, EVELYN JANET
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:JANET
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 1:130 YORKTOWN DR
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-5158
Mailing Address - Country:US
Mailing Address - Phone:804-448-4965
Mailing Address - Fax:877-698-5529
Practice Address - Street 1:130 YORKTOWN DR
Practice Address - Street 2:
Practice Address - City:RUTHER GLEN
Practice Address - State:VA
Practice Address - Zip Code:22546-5158
Practice Address - Country:US
Practice Address - Phone:804-448-4965
Practice Address - Fax:877-698-5529
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12141171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0166339330Medicaid