Provider Demographics
NPI:1013976356
Name:CLEMONS, VIRGINIA LORRAINE SEPICH (RN CPNP)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:LORRAINE SEPICH
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:RN CPNP
Other - Prefix:MS
Other - First Name:VIRGINIA
Other - Middle Name:LORRAINE
Other - Last Name:SEPICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN CPNP
Mailing Address - Street 1:3691 RUTGER AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-977-4440
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104
Practice Address - Country:US
Practice Address - Phone:314-577-5675
Practice Address - Fax:314-268-5111
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104293163WP0200X, 163WX0601X
MO20020346363L00000X, 363LC0200X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WX0601XNursing Service ProvidersRegistered NurseOtorhinolaryngology & Head-Neck
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics