Provider Demographics
NPI:1215167747
Name:RUBIN, STACEY H (APRN)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:H
Last Name:RUBIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WYNDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1144
Mailing Address - Country:US
Mailing Address - Phone:860-231-7679
Mailing Address - Fax:
Practice Address - Street 1:43 WYNDWOOD ROAD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107
Practice Address - Country:US
Practice Address - Phone:860-231-7679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001391363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1215947387Medicaid