Provider Demographics
NPI:1063559052
Name:ROOT, ELIZABETH PARKER (RD, LD, CDE)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:PARKER
Last Name:ROOT
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:P
Other - Last Name:ROOT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD, LD, CDE
Mailing Address - Street 1:530 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32968-2090
Mailing Address - Country:US
Mailing Address - Phone:772-562-6597
Mailing Address - Fax:
Practice Address - Street 1:3755 20TH PL
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-2302
Practice Address - Country:US
Practice Address - Phone:772-562-6597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND789133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE6700Medicare ID - Type Unspecified