Provider Demographics
NPI:1629708052
Name:BLOOM, HALEY BERRYMAN (APRN)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:BERRYMAN
Last Name:BLOOM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321C E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:KY
Mailing Address - Zip Code:40380-2325
Mailing Address - Country:US
Mailing Address - Phone:606-663-9797
Mailing Address - Fax:606-663-9740
Practice Address - Street 1:321C E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:KY
Practice Address - Zip Code:40380-2325
Practice Address - Country:US
Practice Address - Phone:606-663-9797
Practice Address - Fax:606-663-9470
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017926363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty