Provider Demographics
NPI:1407555345
Name:SHEPHERD, REBECCA ASHLEY
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ASHLEY
Last Name:SHEPHERD
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 1:3801 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4801
Mailing Address - Country:US
Mailing Address - Phone:772-221-2003
Mailing Address - Fax:
Practice Address - Street 1:3801 S KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4801
Practice Address - Country:US
Practice Address - Phone:772-221-2003
Practice Address - Fax:772-288-5835
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9117504363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical