Healthcare Provider Details

I. General information

NPI: 1760707558
Provider Name (Legal Business Name): STACEY BUMGARDNER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S HERLONG AVE
ROCK HILL SC
29732-1158
US

IV. Provider business mailing address

1410 PARK WALK PL
ROCK HILL SC
29732-2573
US

V. Phone/Fax

Practice location:
  • Phone: 803-329-6754
  • Fax: 803-985-4521
Mailing address:
  • Phone: 803-329-6754
  • Fax: 803-985-4521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4035
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: