Provider Demographics
NPI:1972373371
Name:ROOTS OF WELLNESS, PLLC.
Entity type:Organization
Organization Name:ROOTS OF WELLNESS, PLLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:SIMONE
Authorized Official - Last Name:HUDGINS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:701-699-4024
Mailing Address - Street 1:19 8TH ST. S. PMB 409
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-699-4024
Mailing Address - Fax:
Practice Address - Street 1:19 8TH ST. S. PMB 409
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1804
Practice Address - Country:US
Practice Address - Phone:701-699-4024
Practice Address - Fax:701-670-2624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-05
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty