1306000815 NPI number — MS. CARRIE SUE SHEPHERD AT

Table of content: MS. CARRIE SUE SHEPHERD AT (NPI 1306000815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306000815 NPI number — MS. CARRIE SUE SHEPHERD AT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEPHERD
Provider First Name:
CARRIE
Provider Middle Name:
SUE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
AT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306000815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 BULLDOG DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLUMERVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72127-8803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-354-2269
Provider Business Mailing Address Fax Number:
501-354-0167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 HIGHWAY 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORRILTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72110-9403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-208-5911
Provider Business Practice Location Address Fax Number:
501-208-5912
Provider Enumeration Date:
07/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 206055721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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