Provider Demographics
NPI:1255756672
Name:BLOOMER, FAYTH (CRNA)
Entity type:Individual
Prefix:
First Name:FAYTH
Middle Name:
Last Name:BLOOMER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26013 ATHERTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-6263
Mailing Address - Country:US
Mailing Address - Phone:312-404-1863
Mailing Address - Fax:
Practice Address - Street 1:40404 CALIFORNIA OAKS RD STE A
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5786
Practice Address - Country:US
Practice Address - Phone:951-304-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000554367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered