Provider Demographics
NPI:1073718268
Name:SHEPHERD, MICHELLE L (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 HOSPITAL DR NE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-8346
Mailing Address - Country:US
Mailing Address - Phone:910-755-8121
Mailing Address - Fax:910-721-1359
Practice Address - Street 1:240 HOSPITAL DR NE
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-8346
Practice Address - Country:US
Practice Address - Phone:910-755-8121
Practice Address - Fax:910-721-1359
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN3273367500000X
NC77503367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1593Medicaid
SCQ346131162Medicare PIN