Basic Information
| Provider Information | |||||||||
| NPI: | 1174954895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUBRAVCIC | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CUSTER | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 710 N. BEAVER ST. #6 | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86001 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 710 N. BEAVER ST. #6 | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285274325 | ||||||||
| FaxNumber: | 9287730756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2013 | ||||||||
| LastUpdateDate: | 12/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP5128 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.