Provider Demographics
NPI:1568057099
Name:HUBBART, THEODORE ARTHUR (LPN)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:ARTHUR
Last Name:HUBBART
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 RENAISSANCE POINTE APT 107
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3526
Mailing Address - Country:US
Mailing Address - Phone:407-301-0448
Mailing Address - Fax:
Practice Address - Street 1:812 RENAISSANCE POINTE APT 107
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-3526
Practice Address - Country:US
Practice Address - Phone:407-301-0448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-06
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5197492164W00000X
AK172082164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse