Basic Information
| Provider Information | |||||||||
| NPI: | 1356741102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | ELISA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 485 VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | MOCKSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270282074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367518000 | ||||||||
| FaxNumber: | 3367518010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2014 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 125085 | NC | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 5007136 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 5007136 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1356741102 | 05 | NC | MEDICAID | 1356741102 | 01 | NC | BCBS | OTHER |