Provider Demographics
NPI:1659092229
Name:FULL BLOOM NUTRITION THERAPY LLC
Entity Type:Organization
Organization Name:FULL BLOOM NUTRITION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MPH, RDN, LDN
Authorized Official - Phone:910-547-2971
Mailing Address - Street 1:3008 FALLEN ACORN CIR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-9438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3008 FALLEN ACORN CIR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-9438
Practice Address - Country:US
Practice Address - Phone:910-547-2971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty