Provider Demographics
NPI:1255803706
Name:MOURICK, SHEILA
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:MOURICK
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 1:25315 PAPILLION DR
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-8848
Mailing Address - Country:US
Mailing Address - Phone:239-776-1822
Mailing Address - Fax:239-236-7287
Practice Address - Street 1:3920 VIA DEL RAY
Practice Address - Street 2:SUITE 4
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134
Practice Address - Country:US
Practice Address - Phone:239-776-1822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL83-2853673Medicaid