Healthcare Provider Details

I. General information

NPI: 1801571369
Provider Name (Legal Business Name): SHERVONNE SIMONE SUPERVILLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 N 1ST ST
FRESNO CA
93726-6821
US

IV. Provider business mailing address

3425 N 1ST ST
FRESNO CA
93726-6821
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 877-960-3426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA210679
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351050948
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: