Provider Demographics
NPI:1669802930
Name:BLOOMER, TINA MARIE (MS, RD/LDN)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:BLOOMER
Suffix:
Gender:F
Credentials:MS, RD/LDN
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:MENDIETA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7035 WALNUT BRANCH LANE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-8939
Mailing Address - Country:US
Mailing Address - Phone:704-607-4924
Mailing Address - Fax:704-469-0879
Practice Address - Street 1:512 BRICKHAVEN DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-1492
Practice Address - Country:US
Practice Address - Phone:704-607-4924
Practice Address - Fax:704-469-0879
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002206133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered