Provider Demographics
NPI:1831886233
Name:BLOOM, AMY LEE
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LEE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3961 95 AVE SW
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:ND
Mailing Address - Zip Code:58656
Mailing Address - Country:US
Mailing Address - Phone:651-592-0211
Mailing Address - Fax:
Practice Address - Street 1:9501 39TH ST SW
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:ND
Practice Address - Zip Code:58656-9763
Practice Address - Country:US
Practice Address - Phone:651-592-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant