=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235604679
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN KAY TUMBLIN NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2018
-----------------------------------------------------
Last Update Date | 10/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 S WENONA ST
-----------------------------------------------------
City | BAY CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48706-8820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-893-8116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 ANDRE ST
-----------------------------------------------------
City | BAY CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48706-5383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-671-2634
-----------------------------------------------------
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 | 4704254478
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------