Provider Demographics
NPI:1134457682
Name:SHEPHERD, EDITH A (APRN LLC)
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:A
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:APRN LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6923 W LONG RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-3466
Mailing Address - Country:US
Mailing Address - Phone:801-662-8951
Mailing Address - Fax:
Practice Address - Street 1:6923 W LONG RIDGE DR
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-3466
Practice Address - Country:US
Practice Address - Phone:801-662-8951
Practice Address - Fax:801-542-0671
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2015-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT225182-4405363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000068346Medicare PIN