Healthcare Provider Details

I. General information

NPI: 1598831315
Provider Name (Legal Business Name): JULIE ANN SUPPLE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE ANN BACKES

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 SAN PABLO ST STE 3800
LOS ANGELES CA
90033-5328
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-5720
  • Fax:
Mailing address:
  • Phone: 323-442-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP95016499
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP7333
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN086670
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberAP7333
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: