Provider Demographics
NPI:1497841951
Name:BLOOM, STEPHANIE ADA (CRNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ADA
Last Name:BLOOM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 E 34TH ST
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4974
Mailing Address - Country:US
Mailing Address - Phone:860-920-2144
Mailing Address - Fax:
Practice Address - Street 1:317 E 34TH ST
Practice Address - Street 2:SUITE 1002
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4974
Practice Address - Country:US
Practice Address - Phone:860-920-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430873-1363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ66249Medicare UPIN
PA099478Medicare ID - Type Unspecified