Provider Demographics
NPI:1407230881
Name:BLOOMINGDALE, TEONNA (LPN)
Entity Type:Individual
Prefix:
First Name:TEONNA
Middle Name:
Last Name:BLOOMINGDALE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4379 PLANTATION BLVD APT 5
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-4010
Mailing Address - Country:US
Mailing Address - Phone:315-451-2142
Mailing Address - Fax:
Practice Address - Street 1:224 HARRISON ST
Practice Address - Street 2:SUITE 680
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3056
Practice Address - Country:US
Practice Address - Phone:315-476-0600
Practice Address - Fax:315-476-4700
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270273164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse