Healthcare Provider Details

I. General information

NPI: 1619067568
Provider Name (Legal Business Name): SALLY ANN BLOMGREN R.N. M.S. C.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 BURNCOAT ST
WORCESTER MA
01605-1350
US

IV. Provider business mailing address

78 BURNCOAT ST
WORCESTER MA
01605-1350
US

V. Phone/Fax

Practice location:
  • Phone: 508-414-5469
  • Fax: 508-870-7684
Mailing address:
  • Phone: 508-414-5469
  • Fax: 508-870-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number151021
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: