Provider Demographics
NPI:1285133280
Name:BLOM, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BLOM
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 1:876 SUNRISE HWY STE 20
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5908
Mailing Address - Country:US
Mailing Address - Phone:631-848-3772
Mailing Address - Fax:631-532-1566
Practice Address - Street 1:876 SUNRISE HWY STE 20
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5908
Practice Address - Country:US
Practice Address - Phone:631-848-3772
Practice Address - Fax:631-532-1566
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5104-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist