Healthcare Provider Details

I. General information

NPI: 1558456152
Provider Name (Legal Business Name): MARIE L. SEDLAK LUPONE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 SHOAL CREEK BLVD STE 130W
AUSTIN TX
78757-1040
US

IV. Provider business mailing address

PO BOX 639295 DEPT 93394
CINCINNATI OH
45263-9295
US

V. Phone/Fax

Practice location:
  • Phone: 512-407-8880
  • Fax:
Mailing address:
  • Phone: 484-346-1692
  • Fax: 855-618-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2023036512
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP007668
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1020694
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: