Healthcare Provider Details

I. General information

NPI: 1881622900
Provider Name (Legal Business Name): JODY LYNN ROOT FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10858 E STATE ROAD 54 SUITE #1
BLOOMFIELD IN
47424-6069
US

IV. Provider business mailing address

10858 E STATE ROAD 54 SUITE #1
BLOOMFIELD IN
47424-6069
US

V. Phone/Fax

Practice location:
  • Phone: 812-400-0067
  • Fax: 812-400-0067
Mailing address:
  • Phone: 812-400-0067
  • Fax: 812-400-0067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002130A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: