Basic Information
| Provider Information | |||||||||
| NPI: | 1619562600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUM | ||||||||
| FirstName: | HANNAH | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 704 S WEBSTER AVE STE 501 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204336050 | ||||||||
| FaxNumber: | 9204336049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2021 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 3471-29 | WI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 86148553 | 01 | COMMISSION ON DIETETIC REGISTRATION | OTHER |