Provider Demographics
NPI:1174212872
Name:BLOOM, NICOLA S
Entity type:Individual
Prefix:MRS
First Name:NICOLA
Middle Name:S
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 1:4429 HOLLYWOOD BLVD # 4562
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33081-6001
Mailing Address - Country:US
Mailing Address - Phone:954-613-9591
Mailing Address - Fax:
Practice Address - Street 1:1317 EDGEWATER DRIVE
Practice Address - Street 2:SUITE 2019
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804
Practice Address - Country:US
Practice Address - Phone:954-613-9591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALPP-315438174N00000X
FL202303071374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN