Provider Demographics
NPI:1083366587
Name:SHEPPARD, GLENDA M
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:M
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16985 CORNERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32820-1913
Mailing Address - Country:US
Mailing Address - Phone:954-358-9754
Mailing Address - Fax:
Practice Address - Street 1:16985 CORNERWOOD DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32820-1913
Practice Address - Country:US
Practice Address - Phone:954-358-9754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004210700Medicaid
FL015064500Medicaid