Healthcare Provider Details

I. General information

NPI: 1336038892
Provider Name (Legal Business Name): MICHELLE PEREA SAUPAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 BREA CANYON RD STE 330
DIAMOND BAR CA
91789-3095
US

IV. Provider business mailing address

179 N AVENIDA ALIPAZ
WALNUT CA
91789-2239
US

V. Phone/Fax

Practice location:
  • Phone: 909-594-3382
  • Fax:
Mailing address:
  • Phone: 626-617-7360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95033937
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: