Provider Demographics
NPI:1790213395
Name:BLOOM, TANNER BENJAMIN I (LPN)
Entity Type:Individual
Prefix:MR
First Name:TANNER
Middle Name:BENJAMIN
Last Name:BLOOM
Suffix:I
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:HOOVERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15936-9012
Mailing Address - Country:US
Mailing Address - Phone:814-798-2098
Mailing Address - Fax:
Practice Address - Street 1:645 RODI RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15235-4564
Practice Address - Country:US
Practice Address - Phone:412-723-2775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN298566164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse