Provider Demographics
NPI:1861480451
Name:RICHARDSON, SHARON PAULETTE
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:PAULETTE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SHARON
Other - Middle Name:PAULETTE
Other - Last Name:TRAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4112 SUSAN AVE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32305-7530
Mailing Address - Country:US
Mailing Address - Phone:850-212-4897
Mailing Address - Fax:
Practice Address - Street 1:4112 SUSAN AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32305-7530
Practice Address - Country:US
Practice Address - Phone:850-656-9199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-09
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL228879171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687526200Medicaid
FL670217196Medicaid