Provider Demographics
NPI:1962683318
Name:KUPERUS, DARLA SUE (RN)
Entity Type:Individual
Prefix:
First Name:DARLA
Middle Name:SUE
Last Name:KUPERUS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1747
Mailing Address - Country:US
Mailing Address - Phone:315-331-4825
Mailing Address - Fax:
Practice Address - Street 1:304 EAST AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1747
Practice Address - Country:US
Practice Address - Phone:315-331-4825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY428077-1163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02888604Medicaid