Provider Demographics
NPI:1861091605
Name:SKUBAK, STACEY C
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:C
Last Name:SKUBAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5729 BLACKHAWK FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-9267
Mailing Address - Country:US
Mailing Address - Phone:614-270-3349
Mailing Address - Fax:
Practice Address - Street 1:5729 BLACKHAWK FOREST DR
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-9267
Practice Address - Country:US
Practice Address - Phone:614-270-3349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376J00000X
OH2107728376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty