Provider Demographics
NPI:1104291749
Name:RUBLE, STEPHANIE (LVN/LPN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:RUBLE
Suffix:
Gender:F
Credentials:LVN/LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6670 E MONTECITO AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-6862
Mailing Address - Country:US
Mailing Address - Phone:559-840-7625
Mailing Address - Fax:
Practice Address - Street 1:6670 E MONTECITO AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-6862
Practice Address - Country:US
Practice Address - Phone:559-840-7625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226505164X00000X
CAVN 274240164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA92896543A84077Medicaid