Provider Demographics
NPI:1003443904
Name:RICHARD, SHEILA (CST, CSFA)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:RICHARD
Suffix:
Gender:F
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 780642
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32978-0642
Mailing Address - Country:US
Mailing Address - Phone:321-508-8756
Mailing Address - Fax:
Practice Address - Street 1:981 TARPON AVE
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-5147
Practice Address - Country:US
Practice Address - Phone:321-508-8756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL138914246ZC0007X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL138914OtherTHE NATIONAL BOARD OF SURGICAL TECHNOLOGIST AND SURGICAL ASSISTING