Provider Demographics
NPI:1689380461
Name:BUBOLZ, NATASHA MAIRE (LPN)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:MAIRE
Last Name:BUBOLZ
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 1:14386 WARRINGTON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:GILLETT
Mailing Address - State:WI
Mailing Address - Zip Code:54124-9793
Mailing Address - Country:US
Mailing Address - Phone:920-598-0712
Mailing Address - Fax:
Practice Address - Street 1:14386 WARRINGTON LAKE DR
Practice Address - Street 2:
Practice Address - City:GILLETT
Practice Address - State:WI
Practice Address - Zip Code:54124-9793
Practice Address - Country:US
Practice Address - Phone:920-598-0712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI325780164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse