Provider Demographics
NPI:1932063310
Name:SUPRE, GINOU
Entity type:Individual
Prefix:
First Name:GINOU
Middle Name:
Last Name:SUPRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23240 FITZPATRICK AVE
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33980-5730
Mailing Address - Country:US
Mailing Address - Phone:239-601-2058
Mailing Address - Fax:
Practice Address - Street 1:23240 FITZPATRICK AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33980-5730
Practice Address - Country:US
Practice Address - Phone:239-601-2058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-10
Last Update Date:2025-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9550663320600000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities