Provider Demographics
NPI:1053912212
Name:BLOOM, BARBARA JANE
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:JANE
Last Name:BLOOM
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 1:474 LITTERAL LN
Mailing Address - Street 2:
Mailing Address - City:ARGILLITE
Mailing Address - State:KY
Mailing Address - Zip Code:41121-8981
Mailing Address - Country:US
Mailing Address - Phone:606-585-7211
Mailing Address - Fax:
Practice Address - Street 1:474 LITTERAL LN
Practice Address - Street 2:
Practice Address - City:ARGILLITE
Practice Address - State:KY
Practice Address - Zip Code:41121-8981
Practice Address - Country:US
Practice Address - Phone:606-585-7211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015487363LF0000X
OH0029777363LF0000X
WV107020363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV107020OtherAPRN