Provider Demographics
NPI:1104344969
Name:TUMPAP, LICEL (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:LICEL
Middle Name:
Last Name:TUMPAP
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 E LA COSTA DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-9738
Mailing Address - Country:US
Mailing Address - Phone:480-628-3066
Mailing Address - Fax:
Practice Address - Street 1:612 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6041
Practice Address - Country:US
Practice Address - Phone:480-834-9039
Practice Address - Fax:480-964-7802
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10091363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner