Healthcare Provider Details

I. General information

NPI: 1205425089
Provider Name (Legal Business Name): MICHELE NICOLE BLOODWORTH ND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 N 9TH AVE PEDS OFFICE BLDG
PENSACOLA FL
32504-8785
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-1026
  • Fax: 850-416-1891
Mailing address:
  • Phone: 904-450-6063
  • Fax: 904-450-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND8501
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: