Provider Demographics
NPI:1407495062
Name:MCCRAY-SHEPPARD, KIZZY MICHELLE
Entity Type:Individual
Prefix:
First Name:KIZZY
Middle Name:MICHELLE
Last Name:MCCRAY-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 1:1588 NE 47TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609-8957
Mailing Address - Country:US
Mailing Address - Phone:352-246-4836
Mailing Address - Fax:
Practice Address - Street 1:4266 SUNBEAM RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-2425
Practice Address - Country:US
Practice Address - Phone:904-268-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004298363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner