Healthcare Provider Details

I. General information

NPI: 1598932683
Provider Name (Legal Business Name): TINA JEAN BUMGARNER ANP C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA BRUNELLI ANP-C

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 EMERSON BAY RD STE 102
CAROLINA SHORES NC
28467-2498
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-579-8363
  • Fax: 910-579-8306
Mailing address:
  • Phone: 910-579-8363
  • Fax: 910-579-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5003968
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: