Provider Demographics
NPI:1811407109
Name:BLOMBERG, BROOKE LORRAINE
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:LORRAINE
Last Name:BLOMBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:LORRAINE
Other - Last Name:CONLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10392 GLEN ROCK CIR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-2692
Mailing Address - Country:US
Mailing Address - Phone:951-903-6931
Mailing Address - Fax:
Practice Address - Street 1:27699 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2661
Practice Address - Country:US
Practice Address - Phone:951-695-4688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB2084708146N00000X
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic