Provider Demographics
NPI:1255454740
Name:KUPSTAS, DOROTHEA JANE (RN)
Entity type:Individual
Prefix:MRS
First Name:DOROTHEA
Middle Name:JANE
Last Name:KUPSTAS
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 1:1 COURTHOUSE SQUARE
Mailing Address - Street 2:
Mailing Address - City:TUNKHANNOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18657-1233
Mailing Address - Country:US
Mailing Address - Phone:570-996-2238
Mailing Address - Fax:570-836-1686
Practice Address - Street 1:1 COURTHOUSE SQUARE
Practice Address - Street 2:HEALTHY FAMILY PARTNERSHIP
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-1233
Practice Address - Country:US
Practice Address - Phone:570-996-2238
Practice Address - Fax:570-836-1686
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN241154L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016392660001Medicaid