Provider Demographics
NPI:1386746360
Name:SEPULVEDA, JUDITH E (MSN)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:E
Last Name:SEPULVEDA
Suffix:
Gender:F
Credentials:MSN
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:2355 POPLAR LEVEL ROAD
Practice Address - Street 2:SUITE G1-11
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1367
Practice Address - Country:US
Practice Address - Phone:502-636-8121
Practice Address - Fax:502-636-8128
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28161288A363L00000X
IN71001781B363L00000X
IN71001781A363L00000X
KY3029P363L00000X
KY3003029363L00000X
KY1071867363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20057650Medicaid
IN211800Medicare ID - Type Unspecified
P62025Medicare UPIN
IN20057650Medicaid
IN547260KKMedicare PIN