Provider Demographics
NPI:1902245442
Name:SRUBAR, LAURIE LYNN (RN-FNP)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:LYNN
Last Name:SRUBAR
Suffix:
Gender:F
Credentials:RN-FNP
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:LYNN
Other - Last Name:BUBELA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3768
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77903-3768
Mailing Address - Country:US
Mailing Address - Phone:361-575-0228
Mailing Address - Fax:361-575-0782
Practice Address - Street 1:605 E SAN ANTONIO ST
Practice Address - Street 2:SUITE 310E
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-6050
Practice Address - Country:US
Practice Address - Phone:361-575-0228
Practice Address - Fax:361-575-0782
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX732558363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171548401Medicaid
TX171548401Medicaid