Organization
PRAIRIE ROOTS WELLNESS, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ERICA ELLICOTT PA-C (PHYSICIAN ASSISTANT)
(308) 883-0658
Entity
Organization
Contact information
Practice address
801 W C ST, MC COOK, NE 69001-3591
(308) 777-2476
(308) 223-5752
Mailing address
PO BOX 565, MC COOK, NE 69001-0565
(308) 777-2476
(308) 223-5752
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10027548401
—
NE
01
—
13552224
CAQH ID
NE
01
—
1902299860
INDIVIDUAL NPI
NE
Enumeration date
02/12/2024
Last updated
02/12/2024
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