Healthcare Provider Details

I. General information

NPI: 1518173087
Provider Name (Legal Business Name): BOBBYJO BLOOM RN, IBCLC, CCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 RANGE RD
WILTON CT
06897-3923
US

IV. Provider business mailing address

209 RANGE RD
WILTON CT
06897-3923
US

V. Phone/Fax

Practice location:
  • Phone: 301-807-3508
  • Fax:
Mailing address:
  • Phone: 203-210-5246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberR143852
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number087534
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number101-17052
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: