Provider Demographics
NPI:1275247264
Name:SHEPPARD, ALTONYA
Entity Type:Individual
Prefix:
First Name:ALTONYA
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 S HOBSON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19142-1804
Mailing Address - Country:US
Mailing Address - Phone:267-221-1324
Mailing Address - Fax:
Practice Address - Street 1:2219 S HOBSON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19142-1804
Practice Address - Country:US
Practice Address - Phone:267-221-1324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 171M00000X
PA13063175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171400000XOther Service ProvidersHealth & Wellness Coach
No175T00000XOther Service ProvidersPeer Specialist