Basic Information
| Provider Information | |||||||||
| NPI: | 1205077112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUPPO | ||||||||
| FirstName: | VERA | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HELM | ||||||||
| OtherFirstName: | VERA | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18615 N CELIS ST | ||||||||
| Address2: | |||||||||
| City: | MARICOPA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852385179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202086121 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 554 S BELLVIEW | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852042504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806491141 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2009 | ||||||||
| LastUpdateDate: | 03/23/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN05067 | AZ | Y | Nursing Service Providers | Registered Nurse |
No ID Information.