Provider Demographics
NPI:1417441130
Name:SHEPHERD, ANNETTE AMBITO (FNP-C)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:AMBITO
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 4TH AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-3813
Mailing Address - Country:US
Mailing Address - Phone:619-422-6158
Mailing Address - Fax:
Practice Address - Street 1:340 4TH AVE STE 11
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910
Practice Address - Country:US
Practice Address - Phone:619-422-6158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-16
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008959363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95008959OtherCALIFORNIA BOARD OF NURSING NURSE PRACTITIONER CERTIFICATE