Provider Demographics
NPI:1073932539
Name:KEPHART, SHEA (RN)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:
Last Name:KEPHART
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93016 MARCOLA RD
Mailing Address - Street 2:
Mailing Address - City:MARCOLA
Mailing Address - State:OR
Mailing Address - Zip Code:97454-9714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:93016 MARCOLA RD
Practice Address - Street 2:
Practice Address - City:MARCOLA
Practice Address - State:OR
Practice Address - Zip Code:97454-9714
Practice Address - Country:US
Practice Address - Phone:541-513-8949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0200040662163W00000X, 163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163W00000XNursing Service ProvidersRegistered Nurse