Provider Demographics
NPI:1881622900
Name:ROOT, JODY LYNN (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JODY
Middle Name:LYNN
Last Name:ROOT
Suffix:
Gender:F
Credentials:FNP-BC
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Other - Credentials:
Mailing Address - Street 1:10858 E STATE ROAD 54
Mailing Address - Street 2:SUITE #1
Mailing Address - City:BLOOMFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:47424-6069
Mailing Address - Country:US
Mailing Address - Phone:812-400-0067
Mailing Address - Fax:812-400-0067
Practice Address - Street 1:10858 E STATE ROAD 54
Practice Address - Street 2:SUITE #1
Practice Address - City:BLOOMFIELD
Practice Address - State:IN
Practice Address - Zip Code:47424-6069
Practice Address - Country:US
Practice Address - Phone:812-400-0067
Practice Address - Fax:812-400-0067
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71002130A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ78851Medicare UPIN