Provider Demographics
NPI:1578808176
Name:SEPULVEDA, SHANNON BROOKE (LM, LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:BROOKE
Last Name:SEPULVEDA
Suffix:
Gender:F
Credentials:LM, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9204 CHARLES E LIMPUS RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-5806
Mailing Address - Country:US
Mailing Address - Phone:321-946-4499
Mailing Address - Fax:407-265-9788
Practice Address - Street 1:710 SUMMER ST
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4021
Practice Address - Country:US
Practice Address - Phone:321-946-4499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5155859164W00000X
174H00000X, 374J00000X
FLMW371176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty