Healthcare Provider Details

I. General information

NPI: 1972345205
Provider Name (Legal Business Name): INBLOOM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 EXETER RD STE 80318
GERMANTOWN TN
38138-3963
US

IV. Provider business mailing address

1185 BRAYSTONE TRL
COLLIERVILLE TN
38017-3648
US

V. Phone/Fax

Practice location:
  • Phone: 901-245-0199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: DEONA DEICKE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 203-641-9529