Provider Demographics
NPI:1649901992
Name:IN BLOOM BIRTH AND WELLNESS PLLC
Entity type:Organization
Organization Name:IN BLOOM BIRTH AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:LEGAULT
Authorized Official - Suffix:
Authorized Official - Credentials:CNM, APRN
Authorized Official - Phone:321-312-1494
Mailing Address - Street 1:2032 SIROCO LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7600
Mailing Address - Country:US
Mailing Address - Phone:321-312-1494
Mailing Address - Fax:
Practice Address - Street 1:1370 SARNO RD STE D
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5230
Practice Address - Country:US
Practice Address - Phone:321-354-6911
Practice Address - Fax:321-617-5786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-17
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1740774470OtherPROVIDER NPI
FLAPRN11000324OtherAPRN LICENSE #