Provider Demographics
NPI:1881842177
Name:STUPPARD, JOHANNE
Entity Type:Individual
Prefix:
First Name:JOHANNE
Middle Name:
Last Name:STUPPARD
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 1:15515 N CONDUIT AVE
Mailing Address - Street 2:APT. 6N
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-4329
Mailing Address - Country:US
Mailing Address - Phone:718-978-4192
Mailing Address - Fax:
Practice Address - Street 1:15515 N CONDUIT AVE
Practice Address - Street 2:APT. 6N
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-4329
Practice Address - Country:US
Practice Address - Phone:718-978-4192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-29
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254537164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse