Basic Information
| Provider Information | |||||||||
| NPI: | 1205425089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOODWORTH | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | ND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD STE 4015 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506063 | ||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 5153 N 9TH AVE | ||||||||
| Address2: | PEDS OFFICE BLDG | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504161026 | ||||||||
| FaxNumber: | 8504161891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2021 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | ND8501 | FL | Y | Dietary & Nutritional Service Providers | Nutritionist |
No ID Information.