Provider Demographics
NPI:1639563307
Name:SUPLIZIO, ILA (DPT)
Entity Type:Individual
Prefix:
First Name:ILA
Middle Name:
Last Name:SUPLIZIO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:588 N SUNRISE AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2842
Mailing Address - Country:US
Mailing Address - Phone:916-782-7848
Mailing Address - Fax:916-782-7855
Practice Address - Street 1:588 N SUNRISE AVE
Practice Address - Street 2:STE. 100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2842
Practice Address - Country:US
Practice Address - Phone:916-782-7848
Practice Address - Fax:916-782-7855
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT42358225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT42358OtherLICENSE
CAZZZ04801ZMedicare UPIN