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General NPI Number Information
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NPI Number | 1649699158
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Entity Type | Individual
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Provider Name | ERICA FAYE SUPRENANT DPM
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Gender | Female
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Dates
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Enumeration Date | 04/11/2014
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Last Update Date | 10/29/2024
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Provider Practice Location Address
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Address Line | 8721 N MAIN ST
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City | DAYTON
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State | OH
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Zip | 45415-1331
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Country | US
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Telephone | 937-264-3150
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Fax | 513-858-7827
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Provider Business Mailing Address
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Address Line | 6200 PLEASANT AVE STE 3
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City | FAIRFIELD
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State | OH
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Zip | 45014-4671
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Country | US
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Telephone | 513-829-9333
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 36003787
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | NY
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