Provider Demographics
NPI:1790530095
Name:SUPIK, CARLA (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:
Last Name:SUPIK
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 415 BLDG 475
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09114
Mailing Address - Country:US
Mailing Address - Phone:314-590-3108
Mailing Address - Fax:
Practice Address - Street 1:CMR 415 BLDG 475
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09114
Practice Address - Country:US
Practice Address - Phone:314-590-3108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR088506163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management