Doctor Name: | MRS. FAWN SHELLEY MUMBULO |
NPI Number: | 1720493984 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | FNP-C |
License Number: | F338835-1 |
Business Practice Address: | 20 Chapel St Sherburne, NY - 134609753 |
Business Phone Number: | 6076742445 |
Business Fax Number: | 6076744338 |
Mailing Address: | Po Box 725, COOPERSTOWN |
State: | NY |
Postal Code: | 133260725 |
Phone Number: | 6076742445 |
Fax Number: | 6076744338 |
NPI Enumeration Date: | 06/26/2014 |
NPI Last Update Date: | 06/27/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | F338835-1 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NY |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |