Healthcare Provider Details

I. General information

NPI: 1497822399
Provider Name (Legal Business Name): MRS. MARILYN BUMGARNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 MCCONVILLE RD
LYNCHBURG VA
24502-4536
US

IV. Provider business mailing address

126 GREEN HILL DR
FOREST VA
24551-4015
US

V. Phone/Fax

Practice location:
  • Phone: 434-237-8886
  • Fax: 434-239-6807
Mailing address:
  • Phone: 434-237-6186
  • Fax: 434-239-6807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024078254
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: