Healthcare Provider Details

I. General information

NPI: 1083576847
Provider Name (Legal Business Name): BLOSSOM PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 CIRBY WAY
ROSEVILLE CA
95678-4235
US

IV. Provider business mailing address

425 CIRBY WAY
ROSEVILLE CA
95678-4235
US

V. Phone/Fax

Practice location:
  • Phone: 409-356-9778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHINONYELUM NZE
Title or Position: CEO
Credential: NP
Phone: 409-356-9778