Provider Demographics
NPI:1336743046
Name:ROOT, LIANE BEVERLY
Entity Type:Individual
Prefix:
First Name:LIANE
Middle Name:BEVERLY
Last Name:ROOT
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 1:7366 S BRITTANY TOWN DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-4609
Mailing Address - Country:US
Mailing Address - Phone:801-889-6063
Mailing Address - Fax:
Practice Address - Street 1:7366 S BRITTANY TOWN DR
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-4609
Practice Address - Country:US
Practice Address - Phone:801-889-6063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8269312-3102163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics