Provider Demographics
NPI:1619067568
Name:BLOMGREN, SALLY ANN (RN MS CS)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:BLOMGREN
Suffix:
Gender:F
Credentials:RN MS CS
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Mailing Address - Street 1:78 BURNCOAT ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1350
Mailing Address - Country:US
Mailing Address - Phone:508-414-5469
Mailing Address - Fax:508-870-7684
Practice Address - Street 1:78 BURNCOAT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1350
Practice Address - Country:US
Practice Address - Phone:508-414-5469
Practice Address - Fax:508-870-7684
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2016-02-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA151021364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPN0758OtherBLUECROSS/BLUE SHIELD
MA2089549OtherCIGNA
MA1034280OtherFALLON
MA411421OtherMAGELLAN
MA471005OtherTUFTS HEALTH PLAN
MA7807539OtherAETNA