Provider Demographics
NPI:1225700560
Name:KUBISEN, KELLY (RNC-NIC, C-ELBW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KUBISEN
Suffix:
Gender:F
Credentials:RNC-NIC, C-ELBW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 GOOD DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-2433
Mailing Address - Country:US
Mailing Address - Phone:717-544-3475
Mailing Address - Fax:
Practice Address - Street 1:690 GOOD DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2433
Practice Address - Country:US
Practice Address - Phone:717-544-3475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PARN659483163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program