Provider Demographics
NPI:1720241623
Name:BLOOM, HANNELORE A (CRNP)
Entity Type:Individual
Prefix:
First Name:HANNELORE
Middle Name:A
Last Name:BLOOM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5523
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:NEUROSCIENCE HOUSE OFFICER OFFICE
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:410-601-1544
Practice Address - Fax:410-601-1543
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR135362363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD416422900Medicaid
MD142163Y0UMedicare PIN
MD416422900Medicaid
MDS576Medicare PIN
MDS567Medicare PIN