Healthcare Provider Details

I. General information

NPI: 1134554751
Provider Name (Legal Business Name): KIRSTEN ELLEN BUBB CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIRSTEN ELLEN LAZORKA

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 11/01/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 BELLEFONTE AVE SUITE #2
LOCK HAVEN PA
17745
US

IV. Provider business mailing address

45 BELLEFONTE AVE SUITE #2
LOCK HAVEN PA
17745
US

V. Phone/Fax

Practice location:
  • Phone: 570-858-5328
  • Fax: 570-858-5355
Mailing address:
  • Phone: 570-858-5328
  • Fax: 570-858-5355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN574721
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP013148
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: