Provider Demographics
NPI:1780732453
Name:BLOOM, JUDITH ANNE (NP)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:ANNE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:1600 BEACON STREET
Mailing Address - Street 2:APARTMENT 207
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446
Mailing Address - Country:US
Mailing Address - Phone:617-312-6904
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVENUE
Practice Address - Street 2:CCE 200
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-667-0245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA186810363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0706442Medicaid
MA0706442Medicaid
MAQ48735Medicare UPIN