Provider Demographics
NPI:1114571445
Name:SHEPHERD, MICHELLE R (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 CANAL SHORE DR SW
Mailing Address - Street 2:
Mailing Address - City:LE CLAIRE
Mailing Address - State:IA
Mailing Address - Zip Code:52753-9564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4600 3RD ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6106
Practice Address - Country:US
Practice Address - Phone:309-779-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019382363LP0808X
IAG154523363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health