Healthcare Provider Details

I. General information

NPI: 1245423912
Provider Name (Legal Business Name): TERESA BARBARA BLOOM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S M 52
WEBBERVILLE MI
48892-9260
US

IV. Provider business mailing address

700 S M 52
WEBBERVILLE MI
48892-9260
US

V. Phone/Fax

Practice location:
  • Phone: 517-521-3540
  • Fax:
Mailing address:
  • Phone: 517-521-3540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number4704208979
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: