Provider Demographics
NPI:1134554751
Name:BUBB, KIRSTEN ELLEN (CRNP)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:ELLEN
Last Name:BUBB
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:ELLEN
Other - Last Name:LAZORKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45 BELLEFONTE AVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745
Mailing Address - Country:US
Mailing Address - Phone:570-858-5328
Mailing Address - Fax:570-858-5355
Practice Address - Street 1:45 BELLEFONTE AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745
Practice Address - Country:US
Practice Address - Phone:570-858-5328
Practice Address - Fax:570-858-5355
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN574721163W00000X
PASP013148363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103171980-0002Medicaid
PA6Z2801OtherMEDICARE PTAN