Provider Demographics
NPI:1174179204
Name:BLOOM, LIZA V (RN)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:V
Last Name:BLOOM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1617
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10925-1617
Mailing Address - Country:US
Mailing Address - Phone:845-754-3242
Mailing Address - Fax:
Practice Address - Street 1:20 OLD TURNPIKE RD STE 307
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-2530
Practice Address - Country:US
Practice Address - Phone:845-624-0260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY729142164W00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse