Healthcare Provider Details

I. General information

NPI: 1164815593
Provider Name (Legal Business Name): NICOLE ROSE BUBNES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 03/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 CHESTNUT STATION CT PARAGON REHABILITATION
LOUISVILLE KY
40299-6395
US

IV. Provider business mailing address

9555 LONGMEADOW ST
FENTON MI
48430-8738
US

V. Phone/Fax

Practice location:
  • Phone: 800-335-1060
  • Fax:
Mailing address:
  • Phone: 810-280-9879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502001933
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: