Healthcare Provider Details

I. General information

NPI: 1548855919
Provider Name (Legal Business Name): LUCILLE ROSE SEPIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2021
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 MEDICAL PARK DR STE 200
DURHAM NC
27704-2389
US

IV. Provider business mailing address

2675 WINKLER AVE STE 200
FORT MYERS FL
33901-9328
US

V. Phone/Fax

Practice location:
  • Phone: 919-471-4484
  • Fax: 919-477-6131
Mailing address:
  • Phone: 877-856-3774
  • Fax: 239-599-2612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-11235
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: