MEDICARE: MICHELE RENEE BLUM FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1017419	TX

General Provider Information

NPI Number	:	1053910877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELE RENEE BLUM FNP-C

Provider Business Mailing Address
First Line	:	3591 MCKINNEY ST STE 400A
Second Line	:
City	:	MELISSA
State	:	TX
Zip	:	75454-9571
Country	:	US
Telephone Number	:	729-464-1611
Fax Number	:

Provider Business Practice Location Address
First Line	:	3591 MCKINNEY ST STE 400A
Second Line	:
City	:	MELISSA
State	:	TX
Zip	:	75454-9571
Country	:	US
Telephone Number	:	729-464-1611
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2020
Last Update Date	:	10/29/2020

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