Healthcare Provider Details

I. General information

NPI: 1023355278
Provider Name (Legal Business Name): LAURIE KUPERSMITH APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14201 W SUNRISE BLVD STE 208
SUNRISE FL
33323-3207
US

IV. Provider business mailing address

14201 W SUNRISE BLVD STE 208
SUNRISE FL
33323-3207
US

V. Phone/Fax

Practice location:
  • Phone: 954-851-9690
  • Fax: 954-851-9688
Mailing address:
  • Phone: 954-851-9690
  • Fax: 954-851-9688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number9217834
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN9217834
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: