Provider Demographics
NPI:1386020774
Name:BLOOM, MELISSA DIANE (MS, RD, LD, CEDRD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MS, RD, LD, CEDRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5830 GRANITE PKWY STE 100-344
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-6771
Mailing Address - Country:US
Mailing Address - Phone:469-991-9865
Mailing Address - Fax:
Practice Address - Street 1:6136 FRISCO SQUARE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-3251
Practice Address - Country:US
Practice Address - Phone:469-991-9865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1007678133V00000X
TXDT85824133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX411003301Medicaid
TX1C4310OtherMEDICARE