Healthcare Provider Details

I. General information

NPI: 1336697895
Provider Name (Legal Business Name): JOHANNA KUBICHEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 PROSPECT AVE
WEST ORANGE NJ
07052-4112
US

IV. Provider business mailing address

328 W SAINT GEORGES AVE
LINDEN NJ
07036-5638
US

V. Phone/Fax

Practice location:
  • Phone: 973-731-6767
  • Fax:
Mailing address:
  • Phone: 908-925-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00407800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: