Healthcare Provider Details

I. General information

NPI: 1811581705
Provider Name (Legal Business Name): BLOOM NUTRITION SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2021
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 BROAD ST
UTICA NY
13501-1203
US

IV. Provider business mailing address

326 BROAD ST
UTICA NY
13501-1203
US

V. Phone/Fax

Practice location:
  • Phone: 315-351-2622
  • Fax: 315-215-2920
Mailing address:
  • Phone: 315-351-2622
  • Fax: 315-215-2920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MS. ALEXANDRA NICOLETTE
Title or Position: REGISTERED DIETITIAN NUTRITIONIST
Credential: RD, CDN
Phone: 315-351-2622