Provider Demographics
NPI:1679521215
Name:SUPPA, ROSANNA PATRICIA (MA CCCLA)
Entity Type:Individual
Prefix:MS
First Name:ROSANNA
Middle Name:PATRICIA
Last Name:SUPPA
Suffix:
Gender:F
Credentials:MA CCCLA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 ELWYN RD
Mailing Address - Street 2:STE B1 YAGO BUILDING
Mailing Address - City:ELWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19063-4622
Mailing Address - Country:US
Mailing Address - Phone:610-891-2216
Mailing Address - Fax:610-891-7000
Practice Address - Street 1:111 ELWYN RD
Practice Address - Street 2:STE B1 YAGO BUILDING
Practice Address - City:ELWYN
Practice Address - State:PA
Practice Address - Zip Code:19063-4622
Practice Address - Country:US
Practice Address - Phone:610-891-2216
Practice Address - Fax:610-891-7000
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT000016L231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030923OtherKEYSTONE MERCY
PA0486041000OtherKEYSTONE HEALTH PLAN EAST
PA01650369Medicaid
PA01650369Medicaid
PA1030923OtherKEYSTONE MERCY