Provider Demographics
NPI:1376137166
Name:VEGA PUPO, SUSSEL
Entity Type:Individual
Prefix:
First Name:SUSSEL
Middle Name:
Last Name:VEGA PUPO
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 1:7898 NW 171ST ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-3842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5441 N UNIVERSITY DR STE 101
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-4640
Practice Address - Country:US
Practice Address - Phone:954-803-9002
Practice Address - Fax:954-933-2305
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF01211301363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily