Basic Information
| Provider Information | |||||||||
| NPI: | 1962929752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUBACKA | ||||||||
| FirstName: | BEATA | ||||||||
| MiddleName: | TERESA | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34 SKUNK MISERY RD | ||||||||
| Address2: | |||||||||
| City: | HIGGANUM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064414435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602096086 | ||||||||
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| Practice Location | |||||||||
| Address1: | 435 LEWIS AVE | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064512101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036948200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 7192 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.