Healthcare Provider Details

I. General information

NPI: 1689583924
Provider Name (Legal Business Name): SUPAPORN PATHUMANON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 LARCHMONT ACRES APT D
LARCHMONT NY
10538-7370
US

IV. Provider business mailing address

814 LARCHMONT ACRES APT D
LARCHMONT NY
10538-7370
US

V. Phone/Fax

Practice location:
  • Phone: 347-845-1857
  • Fax:
Mailing address:
  • Phone: 347-845-1857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SUPAPORN PATHUMANON
Title or Position: PRESIDENT
Credential: PMHNP
Phone: 347-845-1857