Healthcare Provider Details

I. General information

NPI: 1477955979
Provider Name (Legal Business Name): COURTNEY BLOMME RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 HIGHLAND AVE
MADISON WI
53792-0002
US

IV. Provider business mailing address

1675 HIGHLAND AVE MAIL CODE: 1510
MADISON WI
53792-0002
US

V. Phone/Fax

Practice location:
  • Phone: 608-890-5297
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number2758-029
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: