Provider Demographics
NPI:1376633453
Name:SHEPERIS, LAURA (CM, RN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SHEPERIS
Suffix:
Gender:F
Credentials:CM, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 FAIRVIEW ST APT A
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2320
Mailing Address - Country:US
Mailing Address - Phone:762-448-9201
Mailing Address - Fax:
Practice Address - Street 1:1104 BUCHANAN RD STE C10
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4226
Practice Address - Country:US
Practice Address - Phone:925-754-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF001194176B00000X
COAPN.0999550-CNM367A00000X
CA236262367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000227776Medicaid