Provider Demographics
NPI:1366773616
Name:BLOOMBERG, DIANA M (LICENSED PRACTICAL N)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:M
Last Name:BLOOMBERG
Suffix:
Gender:F
Credentials:LICENSED PRACTICAL N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 LIBERTY LANE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0548
Mailing Address - Country:US
Mailing Address - Phone:608-755-9503
Mailing Address - Fax:608-755-9513
Practice Address - Street 1:2112 LIBERTY LANE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0548
Practice Address - Country:US
Practice Address - Phone:608-755-9503
Practice Address - Fax:608-755-9513
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32342-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39996300Medicaid