Provider Demographics
NPI:1407417199
Name:BLOOMINGBURG, ANITA AMANDA (CNA)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:AMANDA
Last Name:BLOOMINGBURG
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5039 W 18TH ST APT 17
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-1962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:829 E 153RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:IL
Practice Address - Zip Code:60426-2554
Practice Address - Country:US
Practice Address - Phone:815-764-6631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide