Ni Ketut Supiyati

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

NP95001498 Issued in CA

Practice address

2638 E Florence Ave
Huntington Park, CA 90255-4708

Phone

(323) 581-4665

Fax

(323) 581-0551

NPI assigned

May 19, 2015

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Interoperability endpoints

• Direct secure messaging: nikki.supayatirnpl.p1@direct.jwch.nextgenshare.com

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1431993600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1431993600000",
    "number": "1023497443",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2638 E FLORENCE AVE",
            "city": "HUNTINGTON PARK",
            "state": "CA",
            "postal_code": "902554708",
            "telephone_number": "323-581-4665",
            "fax_number": "323-581-0551"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2638 E FLORENCE AVE",
            "city": "HUNTINGTON PARK",
            "state": "CA",
            "postal_code": "902554708",
            "telephone_number": "323-581-4665",
            "fax_number": "323-581-0551"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUPIYATI",
        "first_name": "NI KETUT",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2015-05-19",
        "last_updated": "2015-05-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "CA",
            "license": "NP95001498",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "95001498",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Pauline Sullivan, REGISTERED NURSE
• Diamond Monet' Summers
• Sundaram Family Medical Clinic Inc. (Sundaram la Familia Medical Clinic)
• Sundaram Family Medical Clinic, Inc.
• Sunwoong Choi, DDS, MD, Dental Corp
• Natalie Sustaita, NURSE PRACTIONER
• Rhyannon Joan Sutherland
• Suzanne Khalili DDS Inc
• Shakeela Swaby
• Sheila Syacuse

• Nurse Practitioner in Huntington Park, CA
• Providers in Huntington Park, CA by specialty
• Nurse Practitioner in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 19, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.