Provider Demographics
NPI:1598831315
Name:SUPPLE, JULIE ANN (NP-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:SUPPLE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:BACKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5720
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST STE 3800
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5328
Practice Address - Country:US
Practice Address - Phone:323-442-5720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN086670163W00000X
CANP95016499363LA2200X
AZAP7333163WR0006X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ960933Medicaid
AZ960933Medicaid