Individual
KELLIE LEA MUMFORD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
2147 PROFESSIONAL DR, GAYLORD, MI 49735-0003
(989) 732-1753
(989) 731-1425
Mailing address
829 N CENTER AVE, SUITE 298, GAYLORD, MI 49735-1595
(989) 731-7708
(989) 731-7929
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
5601005363
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
OF96004
MEDICARE GROUP NUMBER
—
Enumeration date
08/18/2008
Last updated
12/23/2020
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