Provider Demographics
NPI:1609416528
Name:ROOT, ELIZABETH ELLEN (RN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ELLEN
Last Name:ROOT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-5770
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8628
Practice Address - Street 1:2350 BUHNE ST STE A
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3205
Practice Address - Country:US
Practice Address - Phone:707-443-4593
Practice Address - Fax:707-269-7116
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA752106163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse