Basic Information
| Provider Information | |||||||||
| NPI: | 1467085282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUPRISE | ||||||||
| FirstName: | ELLA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCFADDEN | ||||||||
| OtherFirstName: | ELLA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 928 W 300 N | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846012513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013626352 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6910 S HIGHLAND DR | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD HEIGHTS | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841213060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004348923 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2020 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.