Provider Demographics
NPI:1467216275
Name:PRAIRIE ROOTS WELLNESS, LLC
Entity Type:Organization
Organization Name:PRAIRIE ROOTS WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLICOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:308-883-0658
Mailing Address - Street 1:PO BOX 565
Mailing Address - Street 2:
Mailing Address - City:MC COOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-0565
Mailing Address - Country:US
Mailing Address - Phone:308-777-2476
Mailing Address - Fax:308-223-5752
Practice Address - Street 1:801 W C ST
Practice Address - Street 2:
Practice Address - City:MC COOK
Practice Address - State:NE
Practice Address - Zip Code:69001-3591
Practice Address - Country:US
Practice Address - Phone:308-777-2476
Practice Address - Fax:308-223-5752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10027548401Medicaid
NE13552224OtherCAQH ID
NE1902299860OtherINDIVIDUAL NPI