Provider Demographics
NPI:1912095712
Name:RUBACH, GWEN LEE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:LEE
Last Name:RUBACH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4601
Mailing Address - Country:US
Mailing Address - Phone:616-774-7005
Mailing Address - Fax:616-774-0516
Practice Address - Street 1:175 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-1672
Practice Address - Country:US
Practice Address - Phone:616-527-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704109915363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health