Provider Demographics
NPI:1659030963
Name:SHEPPARD, LACEY JO
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:JO
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 S KNIK GOOSE BAY RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8062
Mailing Address - Country:US
Mailing Address - Phone:907-313-1333
Mailing Address - Fax:
Practice Address - Street 1:591 S KNIK GOOSE BAY RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8062
Practice Address - Country:US
Practice Address - Phone:907-313-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist