Healthcare Provider Details

I. General information

NPI: 1104760537
Provider Name (Legal Business Name): BLOOM PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542194 US HIGHWAY 1
CALLAHAN FL
32011-8109
US

IV. Provider business mailing address

542194 US HIGHWAY 1
CALLAHAN FL
32011-8109
US

V. Phone/Fax

Practice location:
  • Phone: 904-675-3076
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JESSICA RAINES
Title or Position: OWNER
Credential:
Phone: 904-675-3076