Healthcare Provider Details

I. General information

NPI: 1104710581
Provider Name (Legal Business Name): SUSAN KUPSTAS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 N PENNSYLVANIA AVE
WILKES BARRE PA
18701-3603
US

IV. Provider business mailing address

298 RIDGE ST
HANOVER TOWNSHIP PA
18706-3037
US

V. Phone/Fax

Practice location:
  • Phone: 570-491-0126
  • Fax: 570-230-0013
Mailing address:
  • Phone: 570-709-9353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN631817
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP033418
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: