Provider Demographics
NPI:1215945522
Name:ROOT, ODDETH (MSN, RN-BC, NP)
Entity type:Individual
Prefix:MS
First Name:ODDETH
Middle Name:
Last Name:ROOT
Suffix:
Gender:F
Credentials:MSN, RN-BC, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2214
Mailing Address - Country:US
Mailing Address - Phone:817-336-0754
Mailing Address - Fax:817-336-0651
Practice Address - Street 1:431 FULTON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2214
Practice Address - Country:US
Practice Address - Phone:817-336-0754
Practice Address - Fax:817-336-0651
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX462492363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology