1366077695 NPI number — REBEKKA J ROOT FNP

Table of content: REBEKKA J ROOT FNP (NPI 1366077695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366077695 NPI number — REBEKKA J ROOT FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROOT
Provider First Name:
REBEKKA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PROKUP
Provider Other First Name:
REBEKKA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366077695
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 PARK AVENUE EAST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCETON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-876-2293
Provider Business Mailing Address Fax Number:
815-872-6006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2128 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61356-9728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-875-2273
Provider Business Practice Location Address Fax Number:
815-207-8682
Provider Enumeration Date:
03/06/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  209020985 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 209020985 . This is a "STATE OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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