Provider Demographics
NPI:1417945890
Name:SHEPHEARD, BONNIE (CNM)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:SHEPHEARD
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 919771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9771
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:
Practice Address - Street 1:13195 METRO PKWY
Practice Address - Street 2:UNITS 6-9
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4810
Practice Address - Country:US
Practice Address - Phone:239-344-2348
Practice Address - Fax:239-479-5194
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1020612367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL034932100Medicaid
FLFI066ZMedicare Oscar/Certification