Provider Demographics
NPI:1316176068
Name:RUBACKIN-HAYWARD, NICOLE DAWN (DPM)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:DAWN
Last Name:RUBACKIN-HAYWARD
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 MARLBORO RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-1902
Mailing Address - Country:US
Mailing Address - Phone:201-857-4467
Mailing Address - Fax:
Practice Address - Street 1:159 MARLBORO RD
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-1902
Practice Address - Country:US
Practice Address - Phone:201-857-4467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00298400213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine