Provider Demographics
NPI:1699858357
Name:BLOOM, TRACY ROY II (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ROY
Last Name:BLOOM
Suffix:II
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:CASSANDRA
Other - Last Name:SCHNEIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1705 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559-1621
Mailing Address - Country:US
Mailing Address - Phone:707-265-6852
Mailing Address - Fax:
Practice Address - Street 1:1705 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-1621
Practice Address - Country:US
Practice Address - Phone:707-738-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA616687163W00000X
CA14057363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA131881OtherMEDICARE PTAN