Healthcare Provider Details

I. General information

NPI: 1740102573
Provider Name (Legal Business Name): EVAN MITCHELL BLOOM DNP, APRN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 SALBIDE AVE
NEWNAN GA
30263-2501
US

IV. Provider business mailing address

20 SALBIDE AVE
NEWNAN GA
30263-2501
US

V. Phone/Fax

Practice location:
  • Phone: 678-877-6951
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP312467
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: