Healthcare Provider Details

I. General information

NPI: 1245997774
Provider Name (Legal Business Name): DANIELLE BLOOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33654 COUNTY ROAD 19
VONA CO
80861-9703
US

IV. Provider business mailing address

33654 COUNTY ROAD 19
VONA CO
80861-9703
US

V. Phone/Fax

Practice location:
  • Phone: 720-245-7088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number1641652
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: