Provider Demographics
NPI:1093094419
Name:BLOOM, MICHELLE (NP-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:MORMILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:4020 MORSE XING
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-6037
Mailing Address - Country:US
Mailing Address - Phone:614-472-8491
Mailing Address - Fax:
Practice Address - Street 1:4020 MORSE XING
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-6037
Practice Address - Country:US
Practice Address - Phone:614-472-8491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.341314363LA2200X
MI4704295279363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health