Healthcare Provider Details

I. General information

NPI: 1962510412
Provider Name (Legal Business Name): KRISTEN A KUPEYAN MD, MHSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN A BLUE MD, MHSA

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 CENTER POINTE DR STE 102
FORT MYERS FL
33916-9460
US

IV. Provider business mailing address

853 N CHURCH ST STE 510
SPARTANBURG SC
29303-3077
US

V. Phone/Fax

Practice location:
  • Phone: 313-909-1401
  • Fax:
Mailing address:
  • Phone: 864-560-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL27207
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME153506
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: