=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164532966
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY LYNN PUMMILL NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3011 NORTH CENTER RD
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 881-073-6060
-----------------------------------------------------
Fax | 810-736-0323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4759 GOODISON PLACE
-----------------------------------------------------
City | OAKLAND TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48306-1673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-650-9177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 4704091691
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------