Provider Demographics
NPI:1760100663
Name:BLUM, MONIQUE (RD/LDN)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:BLUM
Suffix:
Gender:F
Credentials:RD/LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 SW VALNERA ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2431
Mailing Address - Country:US
Mailing Address - Phone:772-418-4761
Mailing Address - Fax:
Practice Address - Street 1:2324 SW VALNERA ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2431
Practice Address - Country:US
Practice Address - Phone:772-418-4761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7967133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered