Provider Demographics
NPI:1952876823
Name:BLOMSTER, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BLOMSTER
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 1:530 N CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-2950
Mailing Address - Country:US
Mailing Address - Phone:920-427-8773
Mailing Address - Fax:920-574-3503
Practice Address - Street 1:530 N CAMBRIDGE DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-2950
Practice Address - Country:US
Practice Address - Phone:920-427-8773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator