Provider Demographics
NPI:1497402564
Name:BUMBALOUGH, FELICIA RENEE (LLM)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:RENEE
Last Name:BUMBALOUGH
Suffix:
Gender:F
Credentials:LLM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1988 HOG FARM RD
Mailing Address - Street 2:
Mailing Address - City:TILLY
Mailing Address - State:AR
Mailing Address - Zip Code:72679-9731
Mailing Address - Country:US
Mailing Address - Phone:870-504-3124
Mailing Address - Fax:936-228-9586
Practice Address - Street 1:1988 HOG FARM RD
Practice Address - Street 2:
Practice Address - City:TILLY
Practice Address - State:AR
Practice Address - Zip Code:72679-9731
Practice Address - Country:US
Practice Address - Phone:870-504-3124
Practice Address - Fax:936-228-9586
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR012022175M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175M00000XOther Service ProvidersMidwife, Lay