Provider Demographics
NPI:1639555931
Name:ROSENBLOOM, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:ROSENBLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 GLEN DR
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-4511
Mailing Address - Country:US
Mailing Address - Phone:831-901-5503
Mailing Address - Fax:
Practice Address - Street 1:124 GLEN DR
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-4511
Practice Address - Country:US
Practice Address - Phone:831-901-5503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
CA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula