Healthcare Provider Details

I. General information

NPI: 1548714728
Provider Name (Legal Business Name): KELLY M BUMGARNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 ROBERTS DR STE 101
JACKSONVILLE BEACH FL
32250-3253
US

IV. Provider business mailing address

PO BOX 746652
ATLANTA GA
30374-6652
US

V. Phone/Fax

Practice location:
  • Phone: 904-241-7147
  • Fax: 904-376-3213
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9109484
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: