Provider Demographics
NPI:1487122180
Name:BLOOM, PENNY ANN (RN)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:ANN
Last Name:BLOOM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 CLEARWATER CIR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-3081
Mailing Address - Country:US
Mailing Address - Phone:585-259-5001
Mailing Address - Fax:
Practice Address - Street 1:188 CLEARWATER CIR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-3081
Practice Address - Country:US
Practice Address - Phone:585-259-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY674239163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Single Specialty