Provider Demographics
NPI:1902140916
Name:BLOMQUIST, MISTY LYNN (LAC)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:LYNN
Last Name:BLOMQUIST
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 S EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-2821
Mailing Address - Country:US
Mailing Address - Phone:847-226-1047
Mailing Address - Fax:
Practice Address - Street 1:1244 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3936
Practice Address - Country:US
Practice Address - Phone:847-549-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001098171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist