Healthcare Provider Details

I. General information

NPI: 1346596145
Provider Name (Legal Business Name): CAROL KENNER STUMBO ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 S HARBOR CITY BLVD #301
MELBOURNE FL
32901-3245
US

IV. Provider business mailing address

4214 S HIGHWAY A1A UNIT A
MELBOURNE FL
32951-3600
US

V. Phone/Fax

Practice location:
  • Phone: 321-729-9909
  • Fax:
Mailing address:
  • Phone: 321-960-0271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9264218
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: