Provider Demographics
NPI:1710543863
Name:KUBIK, KRISTEN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:KUBIK
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 1:13970 OAKLAND CT
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-5292
Mailing Address - Country:US
Mailing Address - Phone:810-471-2399
Mailing Address - Fax:
Practice Address - Street 1:13970 OAKLAND CT
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-5292
Practice Address - Country:US
Practice Address - Phone:810-471-2399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704299150363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704299150OtherNP LICENSE NUMBER