Provider Demographics
NPI:1952880908
Name:SUPPA, KAITLYN (CASE MANAGER)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:SUPPA
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5149
Mailing Address - Country:US
Mailing Address - Phone:218-287-4338
Mailing Address - Fax:
Practice Address - Street 1:1520 2ND AVE NW
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-1161
Practice Address - Country:US
Practice Address - Phone:218-287-4338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 174400000X
ND247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other