Provider Demographics
NPI:1871721738
Name:BUMGARNER, WENDY LEDAWN
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:LEDAWN
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:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:SELIGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86337-0213
Mailing Address - Country:US
Mailing Address - Phone:928-925-1884
Mailing Address - Fax:
Practice Address - Street 1:297 FORT ROCK ROAD
Practice Address - Street 2:
Practice Address - City:SELIGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86337-0213
Practice Address - Country:US
Practice Address - Phone:928-925-1884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1446366385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child