Healthcare Provider Details

I. General information

NPI: 1306714118
Provider Name (Legal Business Name): BABY BLOSSOM PEDIATRCS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2025
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2463 S M 30
WEST BRANCH MI
48661-9312
US

IV. Provider business mailing address

2172 W NINE MILE RD # 230
PENSACOLA FL
32534-9413
US

V. Phone/Fax

Practice location:
  • Phone: 989-345-3660
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIELLE WALLACE
Title or Position: OWNER/PEDIATRICIAN
Credential: MD
Phone: 616-585-9897