Provider Demographics
NPI:1275090573
Name:SHEPPARD, SHANNON (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N. WOLFE STREET
Mailing Address - Street 2:PHIPPS 546C
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287
Mailing Address - Country:US
Mailing Address - Phone:410-502-5235
Mailing Address - Fax:
Practice Address - Street 1:600 N. WOLFE STREET
Practice Address - Street 2:PHIPPS 546C
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287
Practice Address - Country:US
Practice Address - Phone:410-502-5235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-23
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program