Provider Demographics
NPI:1578146296
Name:VANDER BLOOMEN, NICK THOMAS (PMHNP)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:THOMAS
Last Name:VANDER BLOOMEN
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13936 ROSECRANS RD
Mailing Address - Street 2:
Mailing Address - City:MARIBEL
Mailing Address - State:WI
Mailing Address - Zip Code:54227-9717
Mailing Address - Country:US
Mailing Address - Phone:920-866-8346
Mailing Address - Fax:
Practice Address - Street 1:1505 NORTH DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901
Practice Address - Country:US
Practice Address - Phone:920-426-4310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10856363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health