Provider Demographics
NPI:1851876577
Name:WRUBLE, KELSEY NICOLE (PA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:NICOLE
Last Name:WRUBLE
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 ESTATE ENIGHED
Mailing Address - Street 2:
Mailing Address - City:ST JOHN
Mailing Address - State:VI
Mailing Address - Zip Code:00830-6120
Mailing Address - Country:US
Mailing Address - Phone:740-816-5332
Mailing Address - Fax:
Practice Address - Street 1:5000 ESTATE ENIGHED
Practice Address - Street 2:
Practice Address - City:ST JOHN
Practice Address - State:VI
Practice Address - Zip Code:00830-6120
Practice Address - Country:US
Practice Address - Phone:340-714-4270
Practice Address - Fax:888-979-9488
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7229363A00000X, 363AM0700X, 363AS0400X
VI114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical