Basic Information
| Provider Information | |||||||||
| NPI: | 1720260631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROOT | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOTKE | ||||||||
| OtherFirstName: | CATHERINE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3181 SANDHILL RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488549425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173366060 | ||||||||
| FaxNumber: | 5173366050 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 SANDHILL RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488549425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173366060 | ||||||||
| FaxNumber: | 5173366050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2007 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704179515 | MI | Y | Nursing Service Providers | Registered Nurse |
No ID Information.