Provider Demographics
NPI:1225395742
Name:MACIUBA, BRITTA ZOELLER
Entity type:Individual
Prefix:
First Name:BRITTA
Middle Name:ZOELLER
Last Name:MACIUBA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRITTA
Other - Middle Name:LYNN
Other - Last Name:ZOELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1142
Practice Address - Country:US
Practice Address - Phone:502-348-5968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2015-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48284207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY48284OtherKBML