Healthcare Provider Details

I. General information

NPI: 1528294857
Provider Name (Legal Business Name): SHEEBA PENNICKARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 06/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4285 PATRICK AVE.
WINDSOR ONTARIO
N9G 2X8
CA

IV. Provider business mailing address

4285 PATRICK AVE.
WINDSOR ONTARIO
N9G 2X8
CA

V. Phone/Fax

Practice location:
  • Phone: 519-250-0872
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005433
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: