Healthcare Provider Details

I. General information

NPI: 1609455856
Provider Name (Legal Business Name): STACI BLOOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACI GROTHUES

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 7TH ST BLDG 700700-A
ROBINS AFB GA
31098-2227
US

IV. Provider business mailing address

655 7TH ST BLDG 700700-A
ROBINS AFB GA
31098-2227
US

V. Phone/Fax

Practice location:
  • Phone: 478-327-7850
  • Fax:
Mailing address:
  • Phone: 478-327-7850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11016359
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License NumberAPRN11016359
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: