Provider Demographics
NPI:1194016956
Name:SHEPARD, MICHELLE TAMARA (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:TAMARA
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:TAMARA
Other - Last Name:NORTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:97 SHERMAN DR
Mailing Address - Street 2:NVRH ST JOHNSBURY PEDIATRICS
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9280
Mailing Address - Country:US
Mailing Address - Phone:802-748-5131
Mailing Address - Fax:802-748-4237
Practice Address - Street 1:1 S PROSPECT ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3456
Practice Address - Country:US
Practice Address - Phone:802-847-4696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0012954208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3098587Medicaid
VT1023652Medicaid
VTY400171566Medicare PIN