Healthcare Provider Details

I. General information

NPI: 1003265679
Provider Name (Legal Business Name): MARK SIPE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 09/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16158 S MILITARY TRL
DELRAY BEACH FL
33484-6502
US

IV. Provider business mailing address

3601 N MILITARY TRL
BOCA RATON FL
33431-5507
US

V. Phone/Fax

Practice location:
  • Phone: 561-495-0522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number0001242740
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number93000
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number9430045
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9430045
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: