Provider Demographics
NPI:1033381306
Name:BLOOM, ROSEMARY KAY (RN)
Entity type:Individual
Prefix:MS
First Name:ROSEMARY
Middle Name:KAY
Last Name:BLOOM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:ROSEMARY
Other - Middle Name:KAY
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 377
Mailing Address - Street 2:
Mailing Address - City:BUTTE DES MORTS
Mailing Address - State:WI
Mailing Address - Zip Code:54927-0377
Mailing Address - Country:US
Mailing Address - Phone:920-859-0042
Mailing Address - Fax:920-859-0042
Practice Address - Street 1:5118 LAKEWIND DRIVE
Practice Address - Street 2:
Practice Address - City:BUTTE DES MORTS
Practice Address - State:WI
Practice Address - Zip Code:54927
Practice Address - Country:US
Practice Address - Phone:920-859-0042
Practice Address - Fax:920-859-0042
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73617-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38229100Medicaid