=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083299317
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA KRISTINA LUBKE CMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2021
-----------------------------------------------------
Last Update Date | 03/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 RODGERS ST
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94590-3070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-872-7898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 RODGERS ST
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94590-3070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-872-7898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 01184408
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 79615
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------