1679980668 NPI number — HEATHER N BUMGARDNER NURSE PRACTITIONER

Table of content: HEATHER N BUMGARDNER NURSE PRACTITIONER (NPI 1679980668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679980668 NPI number — HEATHER N BUMGARDNER NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUMGARDNER
Provider First Name:
HEATHER
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679980668
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 W PERRY ST
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31401-3951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-826-1500
Provider Business Mailing Address Fax Number:
912-826-1531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7306 GA HIGHWAY 21
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
PORT WENTWORTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31407-9274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-826-1500
Provider Business Practice Location Address Fax Number:
912-826-1531
Provider Enumeration Date:
07/22/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  RN192027 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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