Healthcare Provider Details

I. General information

NPI: 1124834304
Provider Name (Legal Business Name): CHELSEA REBECCA KUPERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

20 CONRAD AVE
STATEN ISLAND NY
10314-6360
US

IV. Provider business mailing address

20 CONRAD AVE
STATEN ISLAND NY
10314-6360
US

V. Phone/Fax

Practice location:
  • Phone: 917-548-3094
  • Fax:
Mailing address:
  • Phone: 917-548-3094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number747444
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number356276
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: