Healthcare Provider Details

I. General information

NPI: 1073051850
Provider Name (Legal Business Name): FABEOLA SEPOLEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 RIVERSIDE DR
MACON GA
31210-1805
US

IV. Provider business mailing address

4050 RIVERSIDE DR
MACON GA
31210-1805
US

V. Phone/Fax

Practice location:
  • Phone: 478-746-2888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberRN212418
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN212418
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: