Healthcare Provider Details

I. General information

NPI: 1609485481
Provider Name (Legal Business Name): KRISTY LYNN MUMBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTY LYNN BUCKLEY NP

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JOHN ST
KALAMAZOO MI
49007-5341
US

IV. Provider business mailing address

7362 HOPKINTON DR
KALAMAZOO MI
49009-4097
US

V. Phone/Fax

Practice location:
  • Phone: 269-349-9745
  • Fax:
Mailing address:
  • Phone: 248-763-5461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704288323
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: