Healthcare Provider Details

I. General information

NPI: 1740978121
Provider Name (Legal Business Name): BLOOM LACTATION OF TYLER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 WILMA ST
TYLER TX
75701-5644
US

IV. Provider business mailing address

1217 WILMA ST
TYLER TX
75701-5644
US

V. Phone/Fax

Practice location:
  • Phone: 903-805-0233
  • Fax:
Mailing address:
  • Phone: 903-805-0233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number
License Number State

VIII. Authorized Official

Name: TAYLOR CONKEL
Title or Position: LACTATION CONSULTANT
Credential: BSN, RNC-MNN, IBCLC
Phone: 903-805-0233