Provider Demographics
NPI:1942459367
Name:BLOOM, LISA F (NNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:F
Last Name:BLOOM
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:F
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NNP
Mailing Address - Street 1:8091 TOWNSHIP LINE RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2494
Mailing Address - Country:US
Mailing Address - Phone:317-415-7921
Mailing Address - Fax:317-415-7922
Practice Address - Street 1:8091 TOWNSHIP LINE RD
Practice Address - Street 2:SUITE 207
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2494
Practice Address - Country:US
Practice Address - Phone:317-415-7921
Practice Address - Fax:317-415-7922
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001121A363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care