Provider Demographics
NPI:1144298951
Name:CORPUZ, SHAREN R (ARNP)
Entity type:Individual
Prefix:
First Name:SHAREN
Middle Name:R
Last Name:CORPUZ
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W GRANADA BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8157
Mailing Address - Country:US
Mailing Address - Phone:386-615-8122
Mailing Address - Fax:386-615-8135
Practice Address - Street 1:1200 W GRANADA BLVD STE 5
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8157
Practice Address - Country:US
Practice Address - Phone:386-615-8122
Practice Address - Fax:386-615-8135
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1641982363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP03258Medicare UPIN
FLE3893TMedicare PIN