Basic Information
| Provider Information | |||||||||
| NPI: | 1699267963 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOOMQUIST | ||||||||
| FirstName: | DESIRAE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 442 S BLAKELEY ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982722207 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3377 RIVERBEND DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974778803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412226565 | ||||||||
| FaxNumber: | 5412226567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2018 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN60766318 | WA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP60909323 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 202108299NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.