Healthcare Provider Details

I. General information

NPI: 1316240971
Provider Name (Legal Business Name): SUSAN JANE SHEEDY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2010
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5957 W RAMSEY ST
BANNING CA
92220-3058
US

IV. Provider business mailing address

PO BOX 10069 SUITE 101
SAN BERNARDINO CA
92423-0069
US

V. Phone/Fax

Practice location:
  • Phone: 951-846-0313
  • Fax:
Mailing address:
  • Phone: 909-335-4188
  • Fax: 760-777-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number383824
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberNP6910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: