Healthcare Provider Details

I. General information

NPI: 1013976356
Provider Name (Legal Business Name): VIRGINIA LORRAINE SEPICH CLEMONS RN CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIRGINIA LORRAINE SEPICH RN CPNP

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
ST LOUIS MO
63104
US

IV. Provider business mailing address

3691 RUTGER AVE PROVIDER ENROLLMENT
ST LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5675
  • Fax: 314-268-5111
Mailing address:
  • Phone: 314-977-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number104293
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number20020346
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code163WX0601X
TaxonomyOtorhinolaryngology & Head-Neck Registered Nurse
License Number104293
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number20020346
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number20020346
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: