Provider Demographics
NPI:1003992058
Name:SHEPARD, SUSANNA M (FNP)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:M
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:M
Other - Last Name:BYRD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NFP
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1900
Mailing Address - Fax:
Practice Address - Street 1:609 N HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-2179
Practice Address - Country:US
Practice Address - Phone:704-853-5294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005161363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3339776OtherGRANITE STATE MALPRACTICE
SC33N45OtherSC CONTROLLED SUBSTANCES
NC7004977Medicaid