Provider Demographics
NPI:1811347719
Name:DUONG, SUPHATTRA DUEMLER
Entity type:Individual
Prefix:MRS
First Name:SUPHATTRA
Middle Name:DUEMLER
Last Name:DUONG
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 1:604 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-7025
Mailing Address - Country:US
Mailing Address - Phone:714-685-5887
Mailing Address - Fax:
Practice Address - Street 1:729 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-1620
Practice Address - Country:US
Practice Address - Phone:714-865-5887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31148225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist