Healthcare Provider Details

I. General information

NPI: 1528083623
Provider Name (Legal Business Name): CYNTHIA STEPHENS BLOOM ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 ANDREW CARNEGIE BLVD MAIL STOP D101 LIVING WELL, HEALTH AND WELLNESS CENTER
CHARLOTTE NC
28262-8500
US

IV. Provider business mailing address

907 WOODHURST DR
MONROE NC
28110-8545
US

V. Phone/Fax

Practice location:
  • Phone: 704-988-2572
  • Fax: 704-988-4820
Mailing address:
  • Phone: 704-988-2572
  • Fax: 704-988-4820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number222935
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1662822
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: