Provider Demographics
NPI:1952981268
Name:STUMBO, MIKAYLA ELLEN (PA)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:ELLEN
Last Name:STUMBO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 TED STUMBO DR
Mailing Address - Street 2:
Mailing Address - City:HAROLD
Mailing Address - State:KY
Mailing Address - Zip Code:41635-7022
Mailing Address - Country:US
Mailing Address - Phone:859-948-9127
Mailing Address - Fax:
Practice Address - Street 1:127 TED STUMBO DR
Practice Address - Street 2:
Practice Address - City:HAROLD
Practice Address - State:KY
Practice Address - Zip Code:41635-7022
Practice Address - Country:US
Practice Address - Phone:859-323-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-11
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC145363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant