Basic Information
| Provider Information | |||||||||
| NPI: | 1891151403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | SHAWNTAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GADSON | ||||||||
| OtherFirstName: | SHAWNTAY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CLC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3802 WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126638854 | ||||||||
| FaxNumber: | 9123541980 | ||||||||
| Practice Location | |||||||||
| Address1: | 3802 WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126638854 | ||||||||
| FaxNumber: | 9123541980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2016 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174N00000X | 238409 | GA | Y | Other Service Providers | Lactation Consultant, Non-RN |
No ID Information.