Provider Demographics
NPI:1508914854
Name:KUBALA, ELIZABETH FAY (LPN)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:FAY
Last Name:KUBALA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-3300
Mailing Address - Country:US
Mailing Address - Phone:734-285-6455
Mailing Address - Fax:
Practice Address - Street 1:1511 16TH ST
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-3300
Practice Address - Country:US
Practice Address - Phone:734-285-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703045822164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse