MEDICARE: NUBLOOM PMMD PLLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1306637350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NUBLOOM PMMD PLLC

Provider Business Mailing Address
First Line	:	674 WARMINSTER LN
Second Line	:
City	:	LITITZ
State	:	PA
Zip	:	17543-5006
Country	:	US
Telephone Number	:	717-341-9955
Fax Number	:

Provider Business Practice Location Address
First Line	:	14010 COUGAR PT
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-5924
Country	:	US
Telephone Number	:	210-862-8652
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JENNIFER CUTILLO
Credential	:
Telephone Number	:	717-855-4300

Provider Enumeration Date	:	05/16/2025
Last Update Date	:	05/16/2025

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