Healthcare Provider Details

I. General information

NPI: 1174212872
Provider Name (Legal Business Name): MRS. NICOLA S BLOOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 EDGEWATER DRIVE SUITE 2019
ORLANDO FL
32804
US

IV. Provider business mailing address

4429 HOLLYWOOD BLVD # 4562
HOLLYWOOD FL
33081-6001
US

V. Phone/Fax

Practice location:
  • Phone: 954-613-9591
  • Fax:
Mailing address:
  • Phone: 954-613-9591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberALPP-315438
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number202303071
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW24239
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: