Provider Demographics
NPI:1043830524
Name:BRUBAKER, LORI KATHLEEN (LVN)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:KATHLEEN
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 CHEYENNE TRL
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-6145
Mailing Address - Country:US
Mailing Address - Phone:310-717-1625
Mailing Address - Fax:
Practice Address - Street 1:1404 CHEYENNE TRL
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-6145
Practice Address - Country:US
Practice Address - Phone:310-717-1625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174780164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse