Healthcare Provider Details

I. General information

NPI: 1407417199
Provider Name (Legal Business Name): ANITA AMANDA BLOOMINGBURG CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 E 153RD ST
PHOENIX IL
60426-2554
US

IV. Provider business mailing address

5039 W 18TH ST APT 17
CICERO IL
60804-1962
US

V. Phone/Fax

Practice location:
  • Phone: 815-764-6631
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: