Provider Demographics
NPI:1316240971
Name:SHEEDY, SUSAN JANE (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:SHEEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10069
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:760-777-4096
Practice Address - Street 1:5957 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3058
Practice Address - Country:US
Practice Address - Phone:951-846-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA383824363LW0102X
CANP6910363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health