MEDICARE: HALEY BERRYMAN BLOOM APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	3017926	KY

General Provider Information

NPI Number	:	1629708052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALEY BERRYMAN BLOOM APRN

Provider Business Mailing Address
First Line	:	321C E COLLEGE AVE
Second Line	:
City	:	STANTON
State	:	KY
Zip	:	40380-2325
Country	:	US
Telephone Number	:	606-663-9797
Fax Number	:	606-663-9740

Provider Business Practice Location Address
First Line	:	321C E COLLEGE AVE
Second Line	:
City	:	STANTON
State	:	KY
Zip	:	40380-2325
Country	:	US
Telephone Number	:	606-663-9797
Fax Number	:	606-663-9470

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2022
Last Update Date	:	08/02/2022

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Directions to “ HALEY BERRYMAN BLOOM APRN” Practice Location

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