Provider Demographics
NPI:1134837057
Name:ROOTED VIGOR, PLLC
Entity type:Organization
Organization Name:ROOTED VIGOR, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:IYESHIA
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:813-397-8824
Mailing Address - Street 1:7901 4TH ST N STE 11467
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH ST N STE 11467
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4305
Practice Address - Country:US
Practice Address - Phone:813-397-8824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty