Provider Demographics
NPI:1740672229
Name:BLOOM, TAMMY (FNP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 112 BLDG 4
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8055
Mailing Address - Country:US
Mailing Address - Phone:631-574-8354
Mailing Address - Fax:631-751-0506
Practice Address - Street 1:4564 FRANCIS LEWIS BLVD STE 202
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3085
Practice Address - Country:US
Practice Address - Phone:631-751-3000
Practice Address - Fax:631-751-0506
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339372363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily