Provider Demographics
NPI:1790163129
Name:BLOOM, LISA A (IBCLC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:BLOOM
Suffix:
Gender:
Credentials:IBCLC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2719 APPLEBROOK LN
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1150
Mailing Address - Country:US
Mailing Address - Phone:865-582-6585
Mailing Address - Fax:
Practice Address - Street 1:2719 APPLEBROOK LN
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1150
Practice Address - Country:US
Practice Address - Phone:865-582-6585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL-46463174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN