Provider Demographics
NPI:1447487566
Name:ROGERS, AMYLYN VILLENA (IDC)
Entity type:Individual
Prefix:
First Name:AMYLYN
Middle Name:VILLENA
Last Name:ROGERS
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS MESA VERDE LPD 19
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09578-1702
Mailing Address - Country:US
Mailing Address - Phone:757-435-4212
Mailing Address - Fax:
Practice Address - Street 1:USS MESA VERDE LPD 19
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09578-1702
Practice Address - Country:US
Practice Address - Phone:757-435-4212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman