Provider Demographics
NPI:1275929119
Name:SHIPLEY, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:SHIPLEY
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5675
Mailing Address - Fax:
Practice Address - Street 1:6525 3RD ST STE 302
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-5749
Practice Address - Country:US
Practice Address - Phone:321-361-5675
Practice Address - Fax:321-806-3875
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP04318213ES0103X, 213ES0103X
CT1008213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111445400Medicaid
FLN8488OtherFL HF MEDICARE
CT1008OtherPODIATRY LICENSE NUMBER
CT008082422Medicaid