Healthcare Provider Details

I. General information

NPI: 1689380461
Provider Name (Legal Business Name): NATASHA MAIRE BUBOLZ LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14386 WARRINGTON LAKE DR
GILLETT WI
54124-9793
US

IV. Provider business mailing address

14386 WARRINGTON LAKE DR
GILLETT WI
54124-9793
US

V. Phone/Fax

Practice location:
  • Phone: 920-598-0712
  • Fax:
Mailing address:
  • Phone: 920-598-0712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number325780
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: