Provider Demographics
NPI:1376585570
Name:BLOOM, ENID DENISE (MS RD CDN)
Entity Type:Individual
Prefix:MS
First Name:ENID
Middle Name:DENISE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MS RD CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 WELLINGTON RD S
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5519
Mailing Address - Country:US
Mailing Address - Phone:516-564-0186
Mailing Address - Fax:
Practice Address - Street 1:179TH STREET AND LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:ST. ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11425
Practice Address - Country:US
Practice Address - Phone:718-526-1000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001217133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education