Provider Demographics
NPI:1538788732
Name:SUPAK, DYLAN NICOLE
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:NICOLE
Last Name:SUPAK
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 1:675 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-3251
Mailing Address - Country:US
Mailing Address - Phone:979-966-8992
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST STE 420
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3007
Practice Address - Country:US
Practice Address - Phone:832-325-7280
Practice Address - Fax:713-512-7104
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program