Provider Demographics
NPI:1407225238
Name:ROOTVIK, ERIKA
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:
Last Name:ROOTVIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 EASTGATE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-1559
Mailing Address - Country:US
Mailing Address - Phone:509-973-5788
Mailing Address - Fax:509-593-4366
Practice Address - Street 1:2330 EASTGATE ST STE 105
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-1559
Practice Address - Country:US
Practice Address - Phone:509-973-5788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60154855163W00000X
WAAP60607176363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2049449Medicaid