Healthcare Provider Details

I. General information

NPI: 1508007329
Provider Name (Legal Business Name): KACY BLADERGROEN A.R.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 SE SALERNO RD STE 200
STUART FL
34997-6572
US

IV. Provider business mailing address

2150 SE SALERNO RD STE 200
STUART FL
34997-6572
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-5777
  • Fax:
Mailing address:
  • Phone: 772-223-5777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number9264276
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN9264276
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: