Healthcare Provider Details

I. General information

NPI: 1730518390
Provider Name (Legal Business Name): ERICA BLOOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29230 STATE ROUTE 58
SULLIVAN OH
44880-9603
US

IV. Provider business mailing address

29230 STATE ROUTE 58
SULLIVAN OH
44880-9603
US

V. Phone/Fax

Practice location:
  • Phone: 440-935-7084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number154617
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: