Provider Demographics
NPI:1558480749
Name:SHEPHERD, DANA MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:MARIE
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:MARIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1911 COOKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9073
Mailing Address - Country:US
Mailing Address - Phone:360-736-6778
Mailing Address - Fax:360-736-6552
Practice Address - Street 1:1911 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9073
Practice Address - Country:US
Practice Address - Phone:360-736-6778
Practice Address - Fax:360-736-6552
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00145561163WP0200X
WAAP30006273363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2914SMOtherREGENCE
WA9636994Medicaid
WA1194SMOtherREGENCE
WA7057375Medicaid
WA9116SMOtherREGENCE
WA7131717Medicaid
WA7122617Medicaid
WA7131709Medicaid