Healthcare Provider Details

I. General information

NPI: 1992526511
Provider Name (Legal Business Name): SUPATIDA TUANTHET APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 BOSTON POST RD STE 2
GUILFORD CT
06437-2672
US

IV. Provider business mailing address

57 BURGESS ST
EAST HAVEN CT
06512-3709
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 203-430-6671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14125
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: