Provider Demographics
NPI:1225405376
Name:KASUBA, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:KASUBA
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 1:25792 BRIDGEWOOD LN APT 75
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-1030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25792 BRIDGEWOOD LN APT 75
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-1030
Practice Address - Country:US
Practice Address - Phone:734-231-4057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703115080164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse