Provider Demographics
NPI:1477243392
Name:PATHUMANON, SUPAPORN (PMHNP)
Entity type:Individual
Prefix:MISS
First Name:SUPAPORN
Middle Name:
Last Name:PATHUMANON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 VAN NEST AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-3918
Mailing Address - Country:US
Mailing Address - Phone:347-845-1857
Mailing Address - Fax:
Practice Address - Street 1:816 VAN NEST AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-3918
Practice Address - Country:US
Practice Address - Phone:347-845-1857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY738012163W00000X
NYF406141-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse