Healthcare Provider Details

I. General information

NPI: 1205791761
Provider Name (Legal Business Name): ROOTED HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7610 MAIN ST
SYKESVILLE MD
21784-7316
US

IV. Provider business mailing address

405 N CENTER ST STE 25
WESTMINSTER MD
21157-5126
US

V. Phone/Fax

Practice location:
  • Phone: 443-784-3116
  • Fax: 888-649-3015
Mailing address:
  • Phone: 917-861-2531
  • Fax: 888-649-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KISUN PETERS-DIAZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 917-861-2531