Provider Demographics
NPI:1306547674
Name:BLOSSOM NUTRITION
Entity type:Organization
Organization Name:BLOSSOM NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MCQUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN
Authorized Official - Phone:270-484-2111
Mailing Address - Street 1:143 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-2503
Mailing Address - Country:US
Mailing Address - Phone:270-484-2111
Mailing Address - Fax:
Practice Address - Street 1:143 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2503
Practice Address - Country:US
Practice Address - Phone:270-484-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty