Provider Demographics
NPI:1023497443
Name:SUPIYATI, NI KETUT
Entity type:Individual
Prefix:
First Name:NI KETUT
Middle Name:
Last Name:SUPIYATI
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 1:2638 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4708
Mailing Address - Country:US
Mailing Address - Phone:323-581-4665
Mailing Address - Fax:323-581-0551
Practice Address - Street 1:2638 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4708
Practice Address - Country:US
Practice Address - Phone:323-581-4665
Practice Address - Fax:323-581-0551
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95001498363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95001498Medicaid