Healthcare Provider Details

I. General information

NPI: 1407576432
Provider Name (Legal Business Name): TARA LYNN KUPECKI MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 FRANKLINVILLE RD.
LAUREL NY
11948
US

IV. Provider business mailing address

1400 STANLEY RD
MATTITUCK NY
11952-2780
US

V. Phone/Fax

Practice location:
  • Phone: 631-315-7173
  • Fax:
Mailing address:
  • Phone: 631-445-6179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: