Provider Demographics
NPI:1770736522
Name:KUBAL, AMY MARIE
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:KUBAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4521 HOMESTEAD ST
Mailing Address - Street 2:#303
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-0223
Mailing Address - Country:US
Mailing Address - Phone:970-420-1642
Mailing Address - Fax:
Practice Address - Street 1:2450 RISNER DRIVE
Practice Address - Street 2:ELLSWORTH AIR FORCE BASE HEALTH AND WELLNESS CENTER
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706
Practice Address - Country:US
Practice Address - Phone:605-385-2349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00915063133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered