Provider Demographics
NPI:1720493984
Name:MUMBULO, FAWN SHELLEY (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:FAWN
Middle Name:SHELLEY
Last Name:MUMBULO
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:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-0725
Mailing Address - Country:US
Mailing Address - Phone:607-674-2445
Mailing Address - Fax:607-674-4338
Practice Address - Street 1:20 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:SHERBURNE
Practice Address - State:NY
Practice Address - Zip Code:13460-9753
Practice Address - Country:US
Practice Address - Phone:607-674-2445
Practice Address - Fax:607-674-4338
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338835-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily