Provider Demographics
NPI:1417775719
Name:SEVILLA, MARK GUANO
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GUANO
Last Name:SEVILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3088 WRENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-9396
Mailing Address - Country:US
Mailing Address - Phone:518-253-1532
Mailing Address - Fax:
Practice Address - Street 1:2615 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-2223
Practice Address - Country:US
Practice Address - Phone:559-225-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA759419163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health