Healthcare Provider Details

I. General information

NPI: 1558282228
Provider Name (Legal Business Name): BEYOND ROOTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 EAST BLVD STE E
CHARLOTTE NC
28203-5876
US

IV. Provider business mailing address

PO BOX 143
PAW CREEK NC
28130-0143
US

V. Phone/Fax

Practice location:
  • Phone: 980-531-6136
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: VANESSA PERRY
Title or Position: PEDIATRIC NURSE PRACTITIONER
Credential: CPNP
Phone: 585-355-9192