Provider Demographics
NPI:1972326494
Name:BLOMSTEDT, CANDICE TAMARA
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:TAMARA
Last Name:BLOMSTEDT
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 1:8320 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RALSTON
Mailing Address - State:NE
Mailing Address - Zip Code:68127-3726
Mailing Address - Country:US
Mailing Address - Phone:402-682-2771
Mailing Address - Fax:
Practice Address - Street 1:3724 JEFFERSON ST STE 104
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6204
Practice Address - Country:US
Practice Address - Phone:402-682-2771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics