Provider Demographics
NPI:1619021706
Name:SHEPPARD, VICKIE (SLP)
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 ELDRIDGE AVE E
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-4032
Mailing Address - Country:US
Mailing Address - Phone:870-208-8989
Mailing Address - Fax:
Practice Address - Street 1:101 BROUGHAM AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-2505
Practice Address - Country:US
Practice Address - Phone:870-739-9982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP 1566235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR12020540OtherASHA ACCOUNT
AR5X234OtherBLUE CROSS & BLUE SHIELD