Provider Demographics
NPI:1982078622
Name:KUBIAK, NICHOL MICHELLE (RD, CSSD, LMNT)
Entity Type:Individual
Prefix:MRS
First Name:NICHOL
Middle Name:MICHELLE
Last Name:KUBIAK
Suffix:
Gender:F
Credentials:RD, CSSD, LMNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7305 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RALSTON
Mailing Address - State:NE
Mailing Address - Zip Code:68127-3913
Mailing Address - Country:US
Mailing Address - Phone:402-614-5362
Mailing Address - Fax:
Practice Address - Street 1:7305 MAIN ST
Practice Address - Street 2:
Practice Address - City:RALSTON
Practice Address - State:NE
Practice Address - Zip Code:68127-3913
Practice Address - Country:US
Practice Address - Phone:402-614-5362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1238133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered