Healthcare Provider Details

I. General information

NPI: 1841247228
Provider Name (Legal Business Name): ALIDA M. BLOOM RN, CS, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 06/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 S NATIONAL AVE
SPRINGFIELD MO
65804-3634
US

IV. Provider business mailing address

PO BOX 4024
SPRINGFIELD MO
65808-4024
US

V. Phone/Fax

Practice location:
  • Phone: 417-885-3888
  • Fax: 417-881-7638
Mailing address:
  • Phone: 417-885-3888
  • Fax: 417-881-7638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number089317
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number089317
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: