Provider Demographics
NPI:1124279245
Name:BLOOM HEALTH SERVICES FOR WOMEN
Entity type:Organization
Organization Name:BLOOM HEALTH SERVICES FOR WOMEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:SCHLAGEL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:601-487-7141
Mailing Address - Street 1:1200 N STATE ST STE 430
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2027
Mailing Address - Country:US
Mailing Address - Phone:601-487-7141
Mailing Address - Fax:601-487-4170
Practice Address - Street 1:1200 N STATE ST STE 430
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2027
Practice Address - Country:US
Practice Address - Phone:601-487-7141
Practice Address - Fax:601-487-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857552363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02975334Medicaid