Healthcare Provider Details

I. General information

NPI: 1972373371
Provider Name (Legal Business Name): ROOTS OF WELLNESS, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2024
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 8TH ST. S. PMB 409
FARGO ND
58103-1804
US

IV. Provider business mailing address

19 8TH ST. S. PMB 409
FARGO ND
58103
US

V. Phone/Fax

Practice location:
  • Phone: 701-699-4024
  • Fax: 701-670-2624
Mailing address:
  • Phone: 701-699-4024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: GENEVIEVE SIMONE HUDGINS
Title or Position: OWNER/OPERATOR
Credential: APRN
Phone: 701-699-4024