Healthcare Provider Details

I. General information

NPI: 1699267963
Provider Name (Legal Business Name): DESIRAE BLOOMQUIST NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2018
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3377 RIVERBEND DR
SPRINGFIELD OR
97477-8803
US

IV. Provider business mailing address

442 S BLAKELEY ST
MONROE WA
98272-2207
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-6565
  • Fax: 541-222-6567
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60766318
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60909323
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number202108299NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: