Provider Demographics
NPI:1730526633
Name:ROGERS, BEVERLY NAN (LMP)
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:NAN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22707 76TH AVE W APT 226
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8497
Mailing Address - Country:US
Mailing Address - Phone:206-286-7761
Mailing Address - Fax:
Practice Address - Street 1:543 MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3162
Practice Address - Country:US
Practice Address - Phone:206-335-3174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA-3033171W00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No172V00000XOther Service ProvidersCommunity Health Worker