Provider Demographics
NPI:1003680919
Name:BLOOM, MADISON (DNP, FNP-BC)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10040 ROSEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6200 PINE HOLLOW DR STE 400
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-9224
Practice Address - Country:US
Practice Address - Phone:517-339-1676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704341737163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse