Provider Demographics
NPI:1619181039
Name:SHEPHERD, PENNY SUE (DC)
Entity Type:Individual
Prefix:DR
First Name:PENNY
Middle Name:SUE
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-1440
Mailing Address - Country:US
Mailing Address - Phone:740-852-1965
Mailing Address - Fax:740-852-1966
Practice Address - Street 1:714 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1030
Practice Address - Country:US
Practice Address - Phone:419-294-9490
Practice Address - Fax:419-294-2946
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3141111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0059851Medicaid
OH0059851Medicaid