1316415706 NPI number — SHEILA M SHEPHERD FNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316415706 NPI number — SHEILA M SHEPHERD FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEPHERD
Provider First Name:
SHEILA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATHERLY
Provider Other First Name:
SHEILA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316415706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1021 W OAKLAND AVE STE 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37604-2192
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-302-6565
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 BEMBERG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37643-2938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-543-6066
Provider Business Practice Location Address Fax Number:
423-431-2983
Provider Enumeration Date:
11/05/2018

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: 363LF0000X , with the licence number:  0024177476 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 24661 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 24661 . This is a "STATE LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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