Provider Demographics
NPI:1245918549
Name:BLOM, OLIVIA NILDA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:NILDA
Last Name:BLOM
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 1:5251 E EXCHANGE WAY
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-5507
Mailing Address - Country:US
Mailing Address - Phone:208-466-9642
Mailing Address - Fax:208-466-9104
Practice Address - Street 1:5251 E EXCHANGE WAY
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5507
Practice Address - Country:US
Practice Address - Phone:208-466-9642
Practice Address - Fax:208-466-9104
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8652208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation