Provider Demographics
NPI:1922196161
Name:BLOOM, KATHALEEN C (CNM)
Entity Type:Individual
Prefix:
First Name:KATHALEEN
Middle Name:C
Last Name:BLOOM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 E DUVAL ST
Mailing Address - Street 2:VOLUNTEERS IN MEDICINE
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-3201
Mailing Address - Country:US
Mailing Address - Phone:904-399-2766
Mailing Address - Fax:
Practice Address - Street 1:41 E DUVAL ST
Practice Address - Street 2:VOLUNTEERS IN MEDICINE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3201
Practice Address - Country:US
Practice Address - Phone:904-399-2766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP513832367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305057200Medicaid
FLP18950Medicare UPIN
FLY8878ZMedicare ID - Type Unspecified