Healthcare Provider Details

I. General information

NPI: 1932614120
Provider Name (Legal Business Name): REROOT NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2017
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2804 W NORTHERN LIGHTS BLVD
ANCHORAGE AK
99517-3300
US

IV. Provider business mailing address

2804 W NORTHERN LIGHTS BLVD
ANCHORAGE AK
99517-3300
US

V. Phone/Fax

Practice location:
  • Phone: 669-228-5037
  • Fax:
Mailing address:
  • Phone: 669-228-5037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number101188
License Number StateAK

VIII. Authorized Official

Name: KATHERINE SWEETMAN
Title or Position: OWNER, REGISTERED DIETITIAN
Credential: RDN, CSP, LD
Phone: 669-228-5037