Healthcare Provider Details

I. General information

NPI: 1710301361
Provider Name (Legal Business Name): LESLIE BUMPAS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W MAIN ST STE 2
ROGERSVILLE TN
37857-3663
US

IV. Provider business mailing address

850 W MAIN ST STE 2
ROGERSVILLE TN
37857-3663
US

V. Phone/Fax

Practice location:
  • Phone: 423-500-0266
  • Fax: 423-500-4280
Mailing address:
  • Phone: 423-500-0266
  • Fax: 423-500-4280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18354
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: