Basic Information
| Provider Information | |||||||||
| NPI: | 1588734859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | JEANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEIN | ||||||||
| OtherFirstName: | KERRY | ||||||||
| OtherMiddleName: | JEANNE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 279 CASTLE HILL RANCH RD | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945952738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259359563 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2222 BANCROFT EXT | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947204303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106422000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 262915 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 5428 | 01 | CA | NP FURNISHING NUMBER | OTHER | MR0581290 | 01 | CA | DEA NUMBER | OTHER |