Provider Demographics
NPI:1083756829
Name:SHEPHERD, CARISSA (NP)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:
Other - Last Name:WYRICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:GREENTOWN
Practice Address - State:IN
Practice Address - Zip Code:46936-1401
Practice Address - Country:US
Practice Address - Phone:765-628-7041
Practice Address - Fax:765-628-6012
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002240363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200851000Medicaid
IN266180839Medicare PIN
IN200851000Medicaid