Provider Demographics
NPI:1245997774
Name:BLOOM, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33654 COUNTY ROAD 19
Mailing Address - Street 2:
Mailing Address - City:VONA
Mailing Address - State:CO
Mailing Address - Zip Code:80861-9703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33654 COUNTY ROAD 19
Practice Address - Street 2:
Practice Address - City:VONA
Practice Address - State:CO
Practice Address - Zip Code:80861-9703
Practice Address - Country:US
Practice Address - Phone:720-245-7088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1641652163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice