Provider Demographics
NPI:1447674049
Name:ROOT, JEANINE (CRNP)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:ROOT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-371-0600
Mailing Address - Fax:814-372-4764
Practice Address - Street 1:621 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1413
Practice Address - Country:US
Practice Address - Phone:814-371-0600
Practice Address - Fax:814-372-4764
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013693363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA345771OtherMEDICARE PTAN- INDIVIDUAL
PA103135518Medicaid