Provider Demographics
NPI:1255331468
Name:KUBRICHT, DOROTHA W (NP)
Entity Type:Individual
Prefix:
First Name:DOROTHA
Middle Name:W
Last Name:KUBRICHT
Suffix:
Gender:F
Credentials:NP
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 395
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-0395
Mailing Address - Country:US
Mailing Address - Phone:225-683-5292
Mailing Address - Fax:225-683-3411
Practice Address - Street 1:11990 JACKSON ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722-3210
Practice Address - Country:US
Practice Address - Phone:225-683-5292
Practice Address - Fax:225-683-3411
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP01080363LF0000X, 364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1559270Medicaid
LA256220YJA2Medicare PIN
LA4B622D279Medicare PIN
LA4B622Medicare PIN
LAP17190Medicare UPIN