Provider Demographics
NPI:1972098887
Name:DUBIQUE, SHERVON TANYER
Entity type:Individual
Prefix:
First Name:SHERVON
Middle Name:TANYER
Last Name:DUBIQUE
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 1:3630 S PLAZA TRL STE 210J
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-3366
Mailing Address - Country:US
Mailing Address - Phone:757-499-1273
Mailing Address - Fax:757-340-4095
Practice Address - Street 1:3630 S PLAZA TRL STE 210J
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-3366
Practice Address - Country:US
Practice Address - Phone:757-499-1273
Practice Address - Fax:757-340-4095
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker