MEDICARE: MRS. JODY LYNN ROOT FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	71002130A	IN

General Provider Information

NPI Number	:	1881622900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JODY LYNN ROOT FNP-BC

Provider Business Mailing Address
First Line	:	10858 E STATE ROAD 54
Second Line	:	SUITE #1
City	:	BLOOMFIELD
State	:	IN
Zip	:	47424-6069
Country	:	US
Telephone Number	:	812-400-0067
Fax Number	:	812-400-0067

Provider Business Practice Location Address
First Line	:	10858 E STATE ROAD 54
Second Line	:	SUITE #1
City	:	BLOOMFIELD
State	:	IN
Zip	:	47424-6069
Country	:	US
Telephone Number	:	812-400-0067
Fax Number	:	812-400-0067

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	06/22/2015

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