Provider Demographics
NPI:1104391531
Name:ROOT, MARGUERITE G (APRN)
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:G
Last Name:ROOT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6655
Mailing Address - Fax:270-858-4027
Practice Address - Street 1:1025 S MAIN STREET
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-2762
Practice Address - Country:US
Practice Address - Phone:606-340-8870
Practice Address - Fax:606-340-9828
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012786363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100561670Medicaid
14351860OtherCAQH