Healthcare Provider Details

I. General information

NPI: 1649901992
Provider Name (Legal Business Name): IN BLOOM BIRTH AND WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 SARNO RD STE D
MELBOURNE FL
32935-5230
US

IV. Provider business mailing address

2032 SIROCO LN
MELBOURNE FL
32934-7600
US

V. Phone/Fax

Practice location:
  • Phone: 321-354-6911
  • Fax: 321-617-5786
Mailing address:
  • Phone: 321-312-1494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LINDA GAIL LEGAULT
Title or Position: OWNER/PROVIDER
Credential: CNM, APRN
Phone: 321-312-1494