Provider Demographics
NPI:1700766946
Name:BLOM, ELLIE
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:BLOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 OLD CHAPEL HILL RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3605
Mailing Address - Country:US
Mailing Address - Phone:919-286-9595
Mailing Address - Fax:
Practice Address - Street 1:3207 OLD CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-3605
Practice Address - Country:US
Practice Address - Phone:919-286-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAC-2309171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist