Provider Demographics
NPI:1760754683
Name:BUMGARNER, KELLY JOHNSON
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JOHNSON
Last Name:BUMGARNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 BLAZER PKWY
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-3566
Mailing Address - Country:US
Mailing Address - Phone:614-761-1151
Mailing Address - Fax:
Practice Address - Street 1:5720 BLAZER PKWY
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3566
Practice Address - Country:US
Practice Address - Phone:614-761-1151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003813363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical