Provider Demographics
NPI:1477243392
Name:PATHUMANON, SUPAPORN
Entity Type:Individual
Prefix:MISS
First Name:SUPAPORN
Middle Name:
Last Name:PATHUMANON
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 1:8703 CORONA AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-3957
Mailing Address - Country:US
Mailing Address - Phone:347-845-1857
Mailing Address - Fax:
Practice Address - Street 1:4204 LAYTON ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-2363
Practice Address - Country:US
Practice Address - Phone:347-845-1857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY738012163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse