Provider Demographics
NPI:1568980753
Name:SHEPARD, NICOLE MIRENE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MIRENE
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:MIRENE
Other - Last Name:SAUCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:138 EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:GAYS MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:54631-8263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1850 11TH ST AEGIS THERAPIES
Practice Address - Street 2:
Practice Address - City:FENNIMORE
Practice Address - State:WI
Practice Address - Zip Code:53809
Practice Address - Country:US
Practice Address - Phone:608-822-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty