Healthcare Provider Details

I. General information

NPI: 1649699158
Provider Name (Legal Business Name): ERICA FAYE SUPRENANT DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2014
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8721 N MAIN ST
DAYTON OH
45415-1331
US

IV. Provider business mailing address

6200 PLEASANT AVE STE 3
FAIRFIELD OH
45014-4671
US

V. Phone/Fax

Practice location:
  • Phone: 937-264-3150
  • Fax: 513-858-7827
Mailing address:
  • Phone: 513-829-9333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36003787
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: