Provider Demographics
NPI:1497264618
Name:KUBILUS, AMANDA MARIE (CRNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:KUBILUS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:ETTINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:610 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3702
Mailing Address - Country:US
Mailing Address - Phone:570-288-5441
Mailing Address - Fax:570-288-5842
Practice Address - Street 1:743 JEFFERSON AVE STE 203
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1638
Practice Address - Country:US
Practice Address - Phone:570-344-9997
Practice Address - Fax:570-344-3158
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017826363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner