Provider Demographics
NPI:1326635970
Name:BLOOM, IAISA SHIKEMA (APRN)
Entity Type:Individual
Prefix:
First Name:IAISA
Middle Name:SHIKEMA
Last Name:BLOOM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 NW 212TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-1019
Mailing Address - Country:US
Mailing Address - Phone:305-785-7259
Mailing Address - Fax:
Practice Address - Street 1:10301 HAGEN RANCH RD STE B6
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3723
Practice Address - Country:US
Practice Address - Phone:561-752-9490
Practice Address - Fax:561-752-9491
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARPN11010245363LP0808X
FLAPRN11010245363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health