Provider Demographics
NPI:1699312843
Name:HUBBARD, TIMOTHY LEWIS
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LEWIS
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 DEER RUN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-1570
Mailing Address - Country:US
Mailing Address - Phone:810-358-5636
Mailing Address - Fax:
Practice Address - Street 1:851 DEER RUN LAKE RD
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-1570
Practice Address - Country:US
Practice Address - Phone:810-358-5636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704271120163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant