Provider Demographics
NPI:1972013985
Name:KUBISIAK, EMILY HOPE (RD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:HOPE
Last Name:KUBISIAK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:HOPE
Other - Last Name:BAUMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:2820 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3834
Practice Address - Country:US
Practice Address - Phone:715-735-5225
Practice Address - Fax:175-735-5388
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3204-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86098663OtherCOMMISSION ON DIETETIC REGISTRATION