Healthcare Provider Details

I. General information

NPI: 1508864034
Provider Name (Legal Business Name): VANESSA SEPULVEDA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6215 HUMPHREYS BLVD SUITE 200
MEMPHIS TN
38120-2367
US

IV. Provider business mailing address

PO BOX 1000 DEPT 978
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-821-9990
  • Fax: 901-821-9991
Mailing address:
  • Phone: 901-821-9990
  • Fax: 901-821-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28037
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: