Provider Demographics
NPI:1396320859
Name:KUBIK, SHANAE AUDRYONNA
Entity type:Individual
Prefix:
First Name:SHANAE
Middle Name:AUDRYONNA
Last Name:KUBIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANAE
Other - Middle Name:AUDRYONNA
Other - Last Name:VASQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3904 BOULTON CT
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-2050
Mailing Address - Country:US
Mailing Address - Phone:316-209-0765
Mailing Address - Fax:
Practice Address - Street 1:3904 BOULTON CT
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75025-2050
Practice Address - Country:US
Practice Address - Phone:316-209-0765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000040789OtherATHLETIC TRAINING CERTIFICATION NUMBER