Provider Demographics
NPI:1205425089
Name:BLOODWORTH, MICHELE NICOLE (ND)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:NICOLE
Last Name:BLOODWORTH
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:5153 N 9TH AVE
Practice Address - Street 2:PEDS OFFICE BLDG
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8785
Practice Address - Country:US
Practice Address - Phone:850-416-1026
Practice Address - Fax:850-416-1891
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8501133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist