Provider Demographics
NPI:1669879227
Name:SUPENA, DARYL (PT)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:SUPENA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 FAIRFAX RD
Mailing Address - Street 2:APT G
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-4184
Mailing Address - Country:US
Mailing Address - Phone:203-517-8082
Mailing Address - Fax:
Practice Address - Street 1:1703 FAIRFAX RD
Practice Address - Street 2:APT G
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-4184
Practice Address - Country:US
Practice Address - Phone:336-299-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist