Healthcare Provider Details

I. General information

NPI: 1427113430
Provider Name (Legal Business Name): NICOLE BLOOMQUIST OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7214 GREEN BAY RD
KENOSHA WI
53142-3516
US

IV. Provider business mailing address

11103 WEST AVE SUITE 6
SAN ANTONIO TX
78213-1370
US

V. Phone/Fax

Practice location:
  • Phone: 262-694-5464
  • Fax: 262-694-5790
Mailing address:
  • Phone: 210-524-6663
  • Fax: 210-524-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2846-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: