Provider Demographics
NPI:1609485481
Name:MUMBY, KRISTY LYNN
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LYNN
Last Name:MUMBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:LYNN
Other - Last Name:BUCKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:7362 HOPKINTON DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-4097
Mailing Address - Country:US
Mailing Address - Phone:248-763-5461
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-349-9745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704288323363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care