# PRAIRIE ROOTS WELLNESS, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1467216275
- **Authorized official:** ERICA ELLICOTT PA-C (PHYSICIAN ASSISTANT)
- **Authorized official phone:** (308) 883-0658

## Contact information

- **Practice address:** 801 W C ST, MC COOK, NE 69001-3591
- **Practice address phone:** (308) 777-2476
- **Practice address fax:** (308) 223-5752
- **Mailing address:** PO BOX 565, MC COOK, NE 69001-0565
- **Mailing address phone:** (308) 777-2476
- **Mailing address fax:** (308) 223-5752

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363A00000X | Physician Assistant | — | NULL | Yes |
| 363A00000X | Physician Assistant | — | — | Yes |

## Other

- **Enumeration date:** 02/12/2024
- **Last updated:** 02/12/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 10027548401 | — | NE |
| 01 | — | 13552224 | CAQH ID | NE |
| 01 | — | 1902299860 | INDIVIDUAL NPI | NE |