Provider Demographics
NPI:1477347615
Name:ROOTED HEALTH COLLECTIVE
Entity type:Organization
Organization Name:ROOTED HEALTH COLLECTIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYNDALL
Authorized Official - Middle Name:NYESCHELLE
Authorized Official - Last Name:MAMMAH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN FNP-BC
Authorized Official - Phone:954-882-4719
Mailing Address - Street 1:11017 W BROWARD BLVD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1503
Mailing Address - Country:US
Mailing Address - Phone:954-882-4719
Mailing Address - Fax:
Practice Address - Street 1:11017 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1503
Practice Address - Country:US
Practice Address - Phone:954-882-4719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSE WELLNESS SOLUTIONS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-04-04
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty