Provider Demographics
NPI:1366077695
Name:ROOT, REBEKKA J (FNP)
Entity type:Individual
Prefix:
First Name:REBEKKA
Middle Name:J
Last Name:ROOT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:REBEKKA
Other - Middle Name:
Other - Last Name:PROKUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:530 PARK AVENUE EAST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356
Mailing Address - Country:US
Mailing Address - Phone:815-876-2293
Mailing Address - Fax:815-872-6006
Practice Address - Street 1:2128 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-9728
Practice Address - Country:US
Practice Address - Phone:815-875-2273
Practice Address - Fax:815-207-8682
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020985363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209020985OtherSTATE OF ILLINOIS