=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205791761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROOTED HEALTHCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2025
-----------------------------------------------------
Last Update Date | 12/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7610 MAIN ST
-----------------------------------------------------
City | SYKESVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21784-7316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-784-3116
-----------------------------------------------------
Fax | 888-649-3015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 N CENTER ST STE 25
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21157-5126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-861-2531
-----------------------------------------------------
Fax | 888-649-3015
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | KISUN PETERS-DIAZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-861-2531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------