Provider Demographics
NPI:1962929752
Name:KUBACKA, BEATA TERESA (APRN)
Entity type:Individual
Prefix:
First Name:BEATA
Middle Name:TERESA
Last Name:KUBACKA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 SKUNK MISERY RD
Mailing Address - Street 2:
Mailing Address - City:HIGGANUM
Mailing Address - State:CT
Mailing Address - Zip Code:06441-4435
Mailing Address - Country:US
Mailing Address - Phone:860-209-6086
Mailing Address - Fax:
Practice Address - Street 1:435 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2101
Practice Address - Country:US
Practice Address - Phone:203-694-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7192363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner